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COPyRIGHT DEPOSIT. 



Gynecological Pathology 

A Manual of Microscopic Technique and 

Diagnosis in Gynecological Practice 

For Students and Physicians 



BY 

DR. CARL ABEL 

Privat-Docent, Berlin 

TRANSLATED AND EDITED BY 

SAMUEL WYLLIS HANDLER, M.D. 

Adjunct Ciynecologist to the Beth Israel Hospital, New York 



With a Chajiter on the Hinhryolo,i,7 of the Female Genitalia 
and the Pathological Growths Developing from 
Embryonal Structures 



ILLUSTRATED BY ONE HUNDRED ENGRAVINGS 



NEW YORK 

WILLIAM WOOD & COMPANY 

MDCCCCI 



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LIBRARY of CONGRESS 
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Copyright, 19oi 
By WILLIAM WOOD & COMPANY 



PRESS OF STETTINCR BROS., 
52-68 DUANE ST., N. Y, 



TO 

Geh. Med.-Rath Prof. Dr. Waldeyer 

My Highly Esteemed Teacher 

This Book is Dedicated with Feelings of 

Gratitude and Admiration 

Carl Abel 



PREFACE TO THE SECOND EDITION. 



Since the appearance of the valuable investigations of Ruge and Veit, 
the microscopical examination of tissue excised and curetted from the 
uterus has become a necessary adjunct to gynecological diagnosis, so far 
as such diagnosis is concerned with affections of the uterus. The neces- 
sity of this method of diagnosis has been called to the attention of phy- 
sicians by the numerous works on this subject. It is therefore natural 
that a much larger percentage, not only of specialists, but also of general 
practitioners, should seek knowledge of this subject. The numerous indi- 
vidual works scattered in various journals and archives make its study 
a question of time and patience. These works, which follow one or 
another of the numerous questions into minute details, are in nowise 
calculated to interest a beginner. In the large text books this branch of 
gynecology has received attention, but much that is important is dis- 
missed with a few words. To overcome these difficulties is the purpose 
of this book, which is intended to serve as an introduction to practical 
experience. 

Due weight is given to the consideration of normal conditions, for a 
knowledge of these is necessary before one can appreciate pathological 
changes. This is especially true of the uterus, since its structure is nor- 
mally subject to many variations. 

References to the literature are made only where necessary. The 
drawings, which with few exceptions are taken from my specimens, have 
been taken directly from the true microscopical picture, and schematic 
drawings have been avoided, since the latter are not suitable for practical 
instruction. 

The second edition has been considerably enlarged, especially the 
chapters on the vulva, vagina, tubes, and ovaries. Although not treated 
generally in extenso, I have given what my experience has proved to be 
absolutely necessary and of practical gynecological value. 

Carl Abel. 
Berlin, July, 1899. 



PREFACE TO THE TRANSLATION. 



In spite of the glowing results obtained in operations for carcinoma of 
the cervix and uterus, so far as immediate mortality goes, only a small 
percentage fail to suffer from a recurrence of this malignant growth. 
In no branch of medicine, therefore, is an early diagnosis so necessary. 
Since the great majority of patients see their physician before consulting 
a gynecologist, the onus of making a correct diagnosis rests with him, and 
it is his duty to make a test excision from the cervix, or a test curettage 
of the uterus in all cases where the possibility of the presence of a ma- 
lignant growth is suspected. Aside from this the various forms of en- 
dometritis, polypus, sarcoma, etc., can be diagnosed only by microscopi- 
cal examination, and early malignant changes can be recognized. Then 
again the differential diagnosis between abortion and extrauterine gesta- 
tion is all-important and may frequently be made by microscopical ex- 
amination of expelled particles. The value of a microscopical diagnosis 
is also evident in the case of tuberculosis or gonorrhea of the genitalia. 
Having been associated for a long period with Dr. Abel in his pathologi- 
cal work, I realize that this book meets most fully the demands not only 
of the specialist, but also of the beginner, for it is the result of clinical 
experience and is intended for practical purposes only. In translating 
this book, I feel that a most valuable addition is made to our at present 
meagre diagnostic repertory, and that the adoption of methods here de- 
scribed will be the means of saving many a life. The chapter on em- 
bryology and on the origin of growths from embryonal cells and organs 
has been added by me as an aid to the understanding of what is, per- 
haps, the most interesting part of pathology. In no other portion of the 
body are these processes more complex and in no other area is the theory 
of Cohnheim so well exemplified. 

Samuel Wyllis Bandler. 

New York, November, 1901. 




CONTENTS. 



Part I. — Technique. 

PAGE 

I. Material ' 1 

1. Obtaining the Material 2 

(a) Test Excision from the Portio Vaginalis 3 

(ft) Test Curettage of the Endometrium. 4 

(c) Test Excision from the Vagina and External Genitalia. . 4 

II. Further Treatment of the Material Obtained 5 

1. Examination of Fresh Specimens 5 

2. Fixing the Specimens 8 

(a) Muller's Solution 8 

(&) Saturated Watery Solution of Corrosive Sublimate.... 8 

(c) Zenker's Fluid 8 

( d ) Fleming's Solution 8 

3. Hardening and Embedding the Specimens 8 

(a) Glycerin-Gelatin for Fastening the Specimen 9 

(&) Cutting Alcohol Specimens with the Freezing Microtome 10 

(c) The Embedding of Specimens in Celloidin 10 

(d) The Embedding of Specimens in Paraffin 11 

4. Cutting Hardened Embedded Specimens with a Microtome 12 

5. Staining the Sections 13 

(a) Picrolithiocarmin 13 

( & ) Hematoxylin 14 

(c) Staining of Elastic Fibres. 15 

1. Taenzer's Orcein Stain 15 

2. Weigert's Fuchsin-Resorcin Stain 15 

6. Staining of Micro-organisms 16 

(a) The Gonococcus 16 

(a) Dry Cover-Glass Specimens 16 

(/3) Cut Sections 17 

( 6 ) Tubercle Bacillus 17 

(a) Dry Cover-Glass Specimens 17 

ifj ) Cut Sections 18 

III. The Management of Material Obtained by Laparotomy or Autopsy 18 

1. 70 Per Cent. Alcohol 18 

2. Muller's Fluid 18 

3. Formalin 19 

IV. Appendix to Part I. — Instrumentarium 20 

Part II. — Diagnosis. 

I. Vulva 22 

1. Normal Anatomy 22 

2. Pathological Anatomy 23 

(a) Inflammations 23 

(6) Ulcerations 23 



Vlll CONTENTS. 

PAGE 

(c) Atrophies 23 

(d) Hypertrophies 24 

(a) Epithelial 24 

( /3) Connective Tissue 25 

( e ) Neoplasms 25 

(a) Epithelial 25 

1. Carcinoma 25 

2. Cysts 26 

(|3) Connective Tissue 26 

II. Vagina 26 

1. Normal Anatomy 26 

2. Pathological Anatomy 27 

(a) Inflammations 27 

(&) Ulcerations 27 

( c) Hypertrophies 27 

(d) Neoplasms 27 

(a) Epithelial 27 

( /3 ) Connective Tissue 28 

(e) Cysts 28 

III. The Neck of the Uterus (Cervix Uteri) 28 

1. Normal Anatomy , . 29 

Microscopical Illusions 33 

(a) In Sections through the Squamous Epithelium 33 

(&) In Sections through Glands Lined with Cylindrical 

Epithelium 35 

2. Pathological Anatomy 37 

A, Inflammations ' 39 

(a) bimple Inflammation of the Vaginal Portion 39 

( b ) Ulcers of the Vaginal Portion 40 

(c) Ectropion and Inflammation of the Cervical Mucous 

Membrane 42 

(d) Erosions 45 

B. Neoplasms 49 

1. Hypertrophy of the Outer Surface of the Vaginal Portion. . . 49 
(a) Hypertrophy of the Epithelium 49 

( a ) In Prolapse 49 

( (3 ) Condylomata Acuminata 50 

(&) Hypertrophy of the Stroma 51 

( a ) Elongation of the Cervix 52 

( (3 ) Cervical Polypi 52 

2. Carcinoma of the Cervix 57 

3. Malignant Adenoma of the Cervix 66 

4. Sarcoma of the Cervix 66 

5. Myoma, Fibroma, Fibromyoma 68 

6. Tuberculosis of the Cervix 68 

IV. The Body of the Uterus 69 

A. The Mucous Membrane of the Uterus (Endometrium) 70 

1. Normal Anatomy 70 

(a) The Endometrium of the Female after Puberty, in a 

State of Rest 70 

(6) The Endometrium during Menstruation 74 

(c) The Endometrium during the First Months of Intra- 
uterine Pregnancy 78 




CONTENTS. IX 

PAGE 

(d) The Endometrium in Extrauterine Pregnancy 82 

(e) Differential Diagnosis between Menstrual Decidua, 

Uterine Decidua in Intrauterine Pregnancy (Abor- 
tion) , and Extrauterine Gestation 85 

2. Pathological Anatomy 89 

A. General Remarks 89 

B. Inflammation 92 

(a) Interstitial Endometritis 92 

(6) Hypertrophic Endometritis (Fungosa) 94 

(c) Decidual Endometritis 97 

C. Hyperplasia 97 

(a) Hyperplasia of the Entire Endometrium 97 

(a) Diffuse 97 

) /3 ) Circumscribed (Polypoid) 97 

(&) Glandular Hyperplasia of the Endometrium 99 

(a) Diffuse 99 

(/? ) Circumscribed (Polypoid) 100 

D. Neoplasms 100 

(a) Carcinoma of the Endometrium 100 

(&) Malignant Adenoma of the Endometrium 102 

(c) Sarcoma of the Endometrium 104 

( a ) Sarcoma of the Mucous Membrane 104 

( [3 ) Sarcoma of the Uterine Wall 104 

(d) Destructive Neoplasms Arising in Connection with 

Pregnancy 105 

(a) Deciduoma •. 105 

ij3) Chorioma (Waldeyer) 106 

(e) Tuberculosis of the Endometrium 108 

B. The Wall of the Corpus Uteri (Myometrium) 108 

1. Inflammations 108 

2. Neoplasms 109 

Myoma, Fibroma 109 

V. The Tubes 110 

1. Normal Anatomy 110 

(a) Position and Course 110 

(6) Classification of Various Sections of the Tube 110 

(c) Changes Occurring within Normal Limits 114 

( ) Menstruation 114 

( /'? ) Senile Changes 115 

( y ) Changes in Pregnancy 115 

2. Pathological Anatomy 115 

A. Malformations 115 

( a) Infantile Tubes 115 

(&) Accessory Tubes and Tubal Ostia 115 

(c) Hernial Dilatations (Diverticula) of the Tubal Canal.. 116 

(d) Pedunculated or Morgagni's Hydatids 116 

B. Tubal Gestation 116 

(a) Causes 116 

(&) Places of Insertion of the Ovum in the Tube. 117 

(c) Changes in the Tubal Lining in the Region of the Ovum 

in Tubal Gestation 118 

(a) Basal Decidua of the Tube (Serotina) 118 



S CONTENTS. 

PAGE 

(/?) Decidua Vera of the Tube 119 

iy) Capsular Decidua of the Tube (Reflexa) 120 

id) The Tubal Wall in the Region of the Fetal Sac 120 

(e) Chorionic Villi 120 

if) The Portion of the Tube at a Distance from the Fetal Sac, 

and the Tube of the other Side 121 

(g) The Results of Tubal Gestation 121 

C. Disturbances of Circulation 122 

Hematosalpinx 123 

D. Inflammation 124 

(a) General Remarks 124 

(&) Catarrhal Salpingitis 125 

( c) Purulent Salpingitis 127 

(d) Tubo-Ovarian Tumors 134 

E. Infectious Granuloma 137 

F. Hypertrophies and Hyperplasias 137 

G. Neoplasms 138 

VI. Ovaries 139 

1. Normal Anatomy 139 

A. Position and External Form 139 

B. Anatomical Structure 140 

(a) The Vascular Layer 140 

(&) The Parenchymatous Layer 141 

( a ) The Stroma 141 

( ,3 ) The Follicle 141 

1. Follicles in a State of Rest 142 

2. The Graafian Follicle 142 

(c) Further Course of the Ripe Follicle 142 

( a) Corpus Luteum 143 

( /3 ) Corpus Albicans \ 144 

C. The Ovary during Menstruation and Pregnancy 145 

D. Senile Atrophy of the Ovary 145 

2. Pathological Anatomy 145 

A. Ovarian Gestation 145 

B. Disturbances of Circulation, Hyperemia 146 

C. Inflammation 146 

(a) Interstitial Oophoritis 147 

( & ) Perioophoritis 147 

D. Infectious Granuloma 148 

E. Parasites ; 148 

F. Microcystic Degeneration 148 

G. Neoplasms 149 

1. Epithelial Neoplasms 150 

( a) Surfa.ce Papilloma 150 

( (3 ) Follicle Cysts 150 

(y) Corpus-Luteum Cysts 150 

( z/) Cystomata or Cystadenomata of the Ovary 153 

(a) Simple Cystadenoma 153 

(&) Papillary Cystadenoma (Proliferating) 154 

( E ) Carcinoma of the Ovary 157 

2. Connective-Tissue Neoplasms 158 

(a) Fibroma 158 



CONTENTS. XI 

PAGE 

(/5) Myoma 159 

(y) Sarcoma 159 

3. Dermoid Cysts 159 

VII. The Parovarium 160 

1. Normal Anatomy 160 

2. Parovarian Tumors 160 

Part III. — Embryology of the Female Genitalia and the Pathological Growths 

Developing from Embryonal Structures. 

Embryonal Vesicle 164 

Celom 165 

Caudal Intestine 166 

Pronephros 167 

Mesonephros, or Wolffian Body 167 

Wolffian Ducts 170 

Ureter . 172 

Ducts of Miiller 174 

Cloacal Membrane and External Genitalia 175 

Vagina 178 

Kidney 179 

Ovary 180 

Duct of Gartner 181 

Parovarium 182 

(a) Epoophoron 182 

( h ) Paroophoron 182 

Testicle 184 

Parovarian Rests 185 

I. Growths Originating from the Epoophoron 185 

A. Normal Anatomy 186 

B. Pathological Anatomy 186 

( a ) Small Parovarian Cysts 186 

( i3) Large Parovarian Cysts 186 

(y) Adenomata and Fibroadenomata of the Epoophoron 187 

( z/ ) Mesonephritic Adenomata of the Ovary 187 

( t- ) Mesonephritic Cystomata of the Ovary (Ovarian Cysts).... 188 

(a) Simple Serous Cystoma 188 

(&) Papillary Serous Cystadenoma 188 

(c) Glandular or Papillary Pseudomucinous Cystadenoma.. 188 

id) Surface Papilloma 189 

(e) Grape-like Cysts 189 

II. Growths Resulting from the Paroophoron and from Displaced Rests of 

the Wolffian Body ' 189 

A. Normal Anatomy 189 

Displacement of Wolffian Body Cells 191 

B. Pathological Anatomy 191 

( a) Fibroadenoma of the Ligamentum Teres 191 

(j3) Paroophoral Cysts of the Broad Ligament 192 

( X ) Cystomyomata of the Broad Ligament 192 

( z/ ) Adenomata and Fibromata of the Cervix 193 

( 6 ) Adenomata and Cystadenomata of the Posterior Abdominal 

Wall 193 

( C ) Glands and Cysts of the Myometrium 193 

(. 77) Subserous Glands of the Uterus 193 



Xll CONTENTS. 

PAGE 

( 5 ) Retrouterine Subperitoneal Cystomata 194 

(z ) Adenomata of the Tubal Angles 195 

( K ) Adenomyomata of the Uterus and Tubal Angles. . . , 195 

Adenomata of the Uterus and Tubal Corners Originating from the 

Mucosa 199 

Adenomyomata of the Uterus and Tubal Corners Originating from the 

Mucosa 200 

Doubtful Cases 200 

Salpingitis Nodosa Isthmica 201 

Cytogenic Tissue 202 

III. Duct of Gartner and Growths Originating From It 203 

A. Normal Anatomy 203 

B. Pathological Anatomy 205 

( a) Cysts of the Duct of Gartner in the Parametrium 205 

{ft) Cervical Cysts of the Duct of Gartner 205 

{y) Adenomata and Adenocystom.ata of the Duct of Gartner.,.. 206 
(A) Adenomatous Hyperplasia of the Cervical Gland Appendage. 206 

Vaginal Cysts 206 

A. Normal Anatomy 206 

B. Pathological Anatomy 207 

{a) Cysts in the Lateral Wall 208 

{ft) Cysts in the Posterior Wall 208 

{y) Cysts on the Anterior Vaginal Wall 209 

{A) Cysts Scattered over More than One Wall 209 

Cysts of the Labium Minus 210 

A. Normal Anatomy 210 

B. Pathological Anatomy 211 

fV. Tumors Resulting from Cells Displaced by the Wolffian Body and 

Wolffian Duct 212 

A. Normal Anatomy 212 

B. Pathological Anatomy 214 

( oi) Mixed Tumors of the Kidney 214 

{ft) Retroperitoneal Dermoid Cysts 215 

{y) Mixed Tumors and Dermoid Cysts of the Ovary 216 

{A) Mixed Tumors of the Vagina and Cervix Uteri 220 

{ £) Dermoid Cysts of the Cervix 221 

( C) Dermoid Cysts of the Pelvic Connective Tissue 221 

{rj ) Dermoid Cysts of the Uterus 222 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Self-Retaining Speculum 2 

la. Edebohls' Speculum 3 

2. Transferring tlie Section to the Slide 6 

3. Glass Cylinder for Preserving the Specimen to be Examined 9 

4. Longitudinal Section through a Uterus 29 

5. Vaginal Surface of the Cervix Uteri 30 

6. Transition of the Squamous Epithelium of the Portio Vaginalis to 

Cylindrical Epithelium of the Cervical Lining 31 

7. Cervical Mucous Membrane 82 

8. Section through a Pointed Condyloma 34 

9. Longitudinal Section through a Gland lined with Cylindrical 

Epithelium 35 

10. Transverse Section through a Cylindrical Cell 35 

11. Oblique Section through a Gland 35 

12. Section through the Fundus of a Gland 3& 

13. Decubitus Ulcer of the Vaginal Portion in Total Prolapse of the Uterus 41 

14. Test Excision from the Vaginal Portion after Much Cauterization — 

Benign Growth of Epithelium 44 

15. A So-called "Erosion" of the Vaginal Portion 46 

16. Polyp of the Cervix (Originating from the Vaginal Surface) 53 

16a. Cervical Polyp (Originating from the Mucous Membrane of the Cervix) 54 

17. Cervical Polyp with Cysts 55 

18. Carcinoma in a Vein 58 

19. Cells of a Carcinomatous Alveolus with So-called Protozoal Contents. . 61 

20. Cancer Alveolus More Highly Magnified (Fixed in Bichloride) 62 

21. Carcinoma of the Vaginal Portion (Highly Magnified) 63 

22. Carcinoma of the Cervix (General View) 64 

23. Gland whose Wall at one side is Destroyed by Carcinomatous Changes 65 

24. Tuberculosis of the Cervix 69 

25. Almost Normal Endometrium (Slight Increase in the Glands) in its 

Relation to the Muscularis (Low Power) 71 

26. Almost Normal Endometrium (High Power-) 72 

27. Decidua of Menstruation : 77 

28. Decidua in intrauterine Pregnancy (Abortion) at the Second Month 

of Pregnancy 80 

29. Spontaneously Expelled Uterine Decidua in a Tubal Gestation 84 

30. Expelled Piece of Tissue in an Abortion 86 

31. Chorionic Villi (High Power) 87 

31a. Section through a Blood Clot removed from a Uterus after Abortion 

(T^ow Power) 88 



XIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

32. Interstitial Endometritis 93 

33. Hypertrophic Endometritis (Fungosa) 95 

34. Hypertrophic Endometritis with Bleeding into the Glands 96 

35. Circumscribed Hyperplasia of the Whole Endometrium (Polypoid) ... 98 

36. Prom the Polyp "a," Fig. 35, Strongly Magnified 99 

37. Carcinoma of the Endometrium 101 

38. Interstitial Portion of the Tube Ill 

39. Isthmus of the Tube (Near the Ampulla) .^^-^ 112 

40. Fimbriated End of the Tube , rvC 113 

41. Change of the Tubal Mucous Membrane to Decidua 118 

42. Section through the Area of Insertion of the Ovum in a Gravid Tube. . 121 

43. Fimbria with Hyperemia and Lymphatic Congestion 123 

44. Swollen Fold of Tubal Mucosa with Decided Round-Celled Infiltration. 126 

45. Chronic Salpingitis 128 

46. Chronic Purulent Salpingitis 129 

47. Chronic Purulent Salpingitis (Hyperplastic) 130 

48. Chronic Purulent Salpingitis 131 

49. Chronic Purulent Salpingitis with. Atrophy of the Folds (Atrophic) . . 132 

50. Chronic Purulent Salpingitis (Tube Wall) 133 

51. Tubal Abscess 134 

52. Adhesion between Tube and Ovary (Macroscopical) : 135 

53. Tubo-ovarian Tumor 135 

54. Tubo-ovarian Tumor (Low Power) 136 

55. Carcinoma of the Tube 138 

56. Parenchymatous Layer of the Ovary 141 

57. Graafian Follicle 143 

58. From the Wall of a Corpus Luteum 144 

59. Enormous Hypertrophy of the Blood Vessels in an Ovary in a Case 

of Myoma of the Uterus 146 

60. Interstitial Oophoritis 147 

61. Microcystic Degeneration of the Ovary 149 

62. Corpus-Luteum Cyst (Enlarged Three Times) : 151 

63. From the Wall of a Corpus-Luteum Cyst (High Power) 152 

64. Simple Cystadenoma of the Ovary 154 

65. Proliferating Glandular Colloid Cystadenoma (Moderate Magnification) 155 

66. Proliferating Glandular Colloid Cystadenoma (High Power) 156 

67. Carcinoma of the Ovary 157 

68. Glandular Carcinomatous Cystadenoma. 158 

69. Section through the Wall of a Dermoid Cyst of the Ovary (Moderately 

Magnified) 160 

70. From the Wall of a Dermoid Cyst (High Power) 161 

71 Teratoma of the Ovary (Macroscopical) 162 

Part III. 

72. Caudal End of Embryonal Vesicle 164 

73. Middle Blastodermic Layer of Human Embryo 165 

74. Schematic Development of Animal and Vegetative Canals 165 

75. Human Embryo 2.4 mm. Long 166 

76. Caudal End of Human Embryo of 3 mm 166 

77. Pronephros of Ichthyophis Gut, in Transverse Section 167 

78. Rabbit Embryo of 8 Days and 21 Hours — Transverse Section 167 

79. Rabbit Embryo of 8 Days and 23 Hours — Transverse Section 168 

80. Human Embryo of 5 mm. — Transverse Section 168 



LIST OF ILLUSTRATIONS. XV 

FIG. PAGE 

81. Wolffian Body Tubules— Human Embryo of 10.2 mm 169 

82. Human Embryo of 5 mm. — Sagittal Section 169 

83. Transverse Section of Rabbit Embryo, Showing Wolffian Duct 170 

84. Transverse Section through Guinea-pig Embryo 170 

85. Caudal End of Human Embryo of 4.2 mm 171 

86. Caudal End of Human Embryo of 6.5 mm 171 

S7. Pelvic End, Human Embryo of 11.5 mm. (4i/^ weeks) 172 

88. Pelvic End, Human Embryo of 14 mm 173 

89. Transverse Section, Upper End of Wolffian Body of Embryo of 12 mm. 174 

90. Pelvic End, Human Embryo of 29 mm 175 

91. Transverse Section, Human Embryo of 9 Weeks, at Level of the 

Bladder 176 

92. Genital Strand, Human Embryo of 9 Weeks 176 

93. Schematic Arrangement of Internal Genitalia, Human Female Embryo 

of 3-4 cm 177 

94 and 94rt. Ducts of Muller and Wolff, etc., of Fig. 90, Magnified 178 

95. Human Embryo in the Fifth Week 179 

96. Section through Ovary of Human Embryo of 11 cm 180 

97. Wolffian Body and Ovary of Human Embryo of 17 mm 181 

98. Tube, Uterus, and Ovary at Beginning of Third Month 182 

99. Wolffian Duct and Duct of Muller 183 

100 Human Embryo of 4.5 mm. (Third Week) — Transverse Section at 

Level of Arm Formation 213 



PART I. 

TECHNIQUE. 

I. MATERIAL. 

With the development of the bimanual method of examination in 
gynecology, diagnosis has reached such a state of perfection that by 
this means alone certain affections of the uterus or its adnexa may be 
determined with certainty. In a certain class of cases— those in which 
there are changes in the inner surface and in the vaginal portion of the 
uterus— the sense of touch alone does not suffice to make an exact diag- 
nosis. The examining finger is, with justice, called "the eye of the 
gynecologist," yet on palpation we are often liable to illusions, and for 
that reason the sense of sight cannot be dispensed Avith. The introduc- 
tion of the vaginal speculum enables us to view directly the lower part 
of the uterus ; yet this method also fails, because no definite conclusions 
as to the anatomical structure of an affected organ can be made from 
its macroscopical appearance alone. This, added to the fact that the 
inner surface of the uterus is not accessible to the eye, makes it nec- 
essary, in doubtful cases, to remove pieces from the cervix and from the 
lining of the uterus, by test excision and by test curettement, for micro- 
scopical examination. In this manner we are able, by viemng the 
pathological specimens, to verify a previous clinical diagnosis. That 
even then an absolute, positive statement cannot be made will be shown 
more clearly later on. Nevertheless, the importance of such an ex- 
amination is evident; for upon its result will always depend the ob- 
jective and scientific basis for therapeutic action. 

The affections of the external genitalia and of the vagina lead to a 
microscopical examination only in rare cases. This method is chiefly 
made use of in pathological conditions of the portio vaginalis, the 
cervix, and the endometrium. 

Harpooning large abdominal tumors is now entirely discontinued, 
since exploratory laparotomies have been generally accepted. Like- 
wise the microscopical examination of fluid obtained by puncture leads 
to a positive result only in those cases in which specific form elements 
are found, viz., echinococcus booklets, etc. Otherwise more knowledge 
is gained by chemical examination, if a preliminary observation be 
needed to form a diagnosis. 



Z MATERIAL. 

1. OBTAINING THE MATERIAL. 

Before removing a portion of the uterus a precise history of each 
case should be obtained, and a bimanual examination then determines 
whether an affection of the cervix or of the body of the uterus is present. 
It is necessary from the beginning to know whether a test excision from 
the cervix or a test curettement of the cavity of the uterus is required. 

In carrying out this slight procedure it is necessary to expose the 
organ as far as possible. If done with assistance, it is better to use 
the Sims-Simon anterior and posterior specula. The anterior lip of the 
cervix is grasped by means of a bullet forceps or a uterine clamp and 
is carefully drawn down, and firmly fixed after removing the anterior 
speculum. 

It may be mentioned that care is needed in the procedure, so that 
ioo much tension should not be exerted if the adnexa of the uterus are 




Figure 1. 



not quite free; for then a parametritis or an inflammatory condition 
of the tubes is present, and careless or violent traction upon the uterus 
m^y easily cause great harm. The presence of such a condition should 
be, to the beginner, a contraindication. 

. If no assistance is at hand, a self-supporting speculum may be used 
to advantage. There are many such specula; any one is good which 
accomplishes the chief requisite— viz., no interference with the instru- 
ments used or with freedom of movement. For this purpose I 
use, as a rule, a speculum modified by L. Landau and myself, 
which has the special advantage that it may be attached not only 
to the examining table but also to any table or bed. It is there- 
fore suited to the use of the general practitioner. It consists of 
a binding screw with spaces for a horizontal arm (Fig. 1) which ends 
in a ball-and-socket joint. The latter is intended to hold the rather 



TEST EXCISION. 3 

long rod on wliicli the usual Simon speculum is fitted. The joint, if 
tightened, permits of fixing the speculum in any desired position and 
follows as far as may be needed the movement of the hand. When the 
speculum has been placed in the necessary position and fastened there 
by a screw, both hands are free to introduce the anterior speculum, to 
grasp the uterus, and to carry out further manipulations ^rithout special 
difficulty. The self-retaining speculum of Neugebauer, junior, may be 
especially recommended, as well as the speculum of Edebohls (Fig. la). 

(a) Test Excision from the Cervix. 

No especial preparations are needed in making a test excision from 
the portio vaginalis. After introduction of the speculum, the vagina 




Figure la. — Edebohls-' SPEcrLr:M. 

and external surface of the cervix should be thoroughly cleansed wifh. 
a three per cent solution of carbolic acid or with a 1 : 5000 bichloride 
solution. It is best to first irrigate the parts and then energetically 
wash them with cotton dipped in this solution. 

After fixing the anterior lip of the cer^dx with the forceps, a wedge- 
shaped piece is cut from the desired area with Cooper's or any other 
angular scissors. Care should be taken to remove not only the affected 
portion, but, if possible, to select an area which shows the transition 
from healthy to diseased tissue. The resulting bleeding can usually be 
arrested by packing with cotton, yet at times one or two ligatures may 
be needed. At any rate, it should be made a general rule that the 
patient lie quietly for some time after, to convince one's self that the 
bleedino; has entirelv ceased, for in some cases, even after such a slight 



4 TEST CURETTAGE. 

procedure, severe bleedings may result unless sufficient precaution has 
been taken. 

(b) Test Curettage op the Endometrium. 

After disinfection of the vagina and traction upon the cervix, the 
length and course of the uterine canal must be determined with the 
sound, and the permeability of the internal os, as well as any perceptible 
changes in the mucous membrane, must be recognized. 

I consider it absolutely inadvisable to probe the uterus blindly 
without introducing the speculum, since it is impossible to be certain 
that this is performed mth perfect asepsis. This naturally holds good 
also for the curettage and for every instrumental intrauterine pro- 
cedure. 

Under control of the eye we enter the uterine cavity with a middle- 
sized curette and remove the mucous membrane by energetic move- 
ments from above downward. The small particles thus obtained are 
caught in a clean glass held in front of the speculum. In most cases 
this comparatively simple method suffices. If, however, the amount of 
mucous membrane obtained is insufficient for microscopical examina- 
tion, or if it be thought that the affected areas have not been obtained, 
it is advisable to dilate the cervix and then penetrate to the fundus 
with the finger. In this way the pathological region may be felt with 
greater certainty and a portion removed with the finger or scraped 
away mth a sharp spoon. If the uterus be once dilated so that the 
examining finger easily enters it, there is no danger in energetically 
scraping with a spoon. It is certain that mth this instrument more 
material may be obtained than with the curette. 

By what means the dilatation of the cervix shall be accomplished 
is a matter for the individual operator to decide. Some prefer rapid, 
others gradual dilatation. The former can be easily done with the 
Fritsch dilators ; the latter is best attained by the introduction of iodo- 
form gauze into the uterine cavity. I always use the latter method 
according to the suggestion of L. Landau. With a metal introducer a 
strip of gauze five metres long is pushed up to the fundus and the 
uterine cavity packed as tightly as possible. The remainder of the 
strip fills out the cervix and is held by a cotton tampon placed in 
front of the cervix. The gauze is left for twenty-four hours, when 
in mosl cases the examining finger may be introduced without difficulty. 
If, however, this be impossible, it is necessary to renew this packing 
only once to obtain the desired result, even in the case of the virgin 
uterus. This procedure should, if possible, not be an ambulatory one. 

(c) Test Excision from the Vagina and External Genitalia. 

In the case of doubtful macroscopical affections of the vagina or ex- 
ternal genitalia a portion of the diseased tissue may be removed, under 



FURTHER TREATMENT OF THE MATERIAL OBTAINED. 5 

aseptic precautions, with scissors or the knife; the bleeding is stopped 
by suture or by a dressing. 



II. FURTHER TREATMENT OF THE MATERIAL OBTAINED. 

The excised pieces, or the particles curetted from the uterus, are 
cleaned under slowly running water and are then viewed with the 
naked eye or through a magnifying glass. A close examination of the 
specimen in this fresh, so-called ''li^dng" condition should never be 
neglected; for its color, consistence, and character must be observed. 
At times it is of advantage to make a sketch and an exact record, since 
subsequent manipulations essentially change the appearance of the 
specimen. Therefore it is advisable, at the same time, to decide what 
method of hardening will be adopted for its microscopical examination, 
and in what direction the sections are later to be made. 

The method of preparing the material depends essentially on the 
quantity at our disposal. Contrary to general pathological exam- 
inations, where, as a rule, larger portions of the various organs are 
used, we usually in these cases have to do with small bits. Therefore, 
although the examination in a fresh condition is to be desired, we are 
often unable to do so ; for we must consider that the examination of 
fresh specimens often furnishes no positive means of diagnosis, as only 
the examination of numerous sections shows us the true nature of 
the affection. To examine the lining specimen it is necessary to divide 
it, so that eventually the other half may be embedded. As a rule, how- 
ever, the material is not sufficient to permit of such a course, especially 
that obtained by a test curettage. 

On the other hand, a dangerous operation often depends -on the 
microscopical diagnosis made from relatively very small bits of tissue. 
Therefore it is necessary to use all the finer means placed at our dis- 
posal through modern microscopical technique in making such a diag- 
nosis positive. For that reason I advise that an excised portion of the 
cervix be so divided that one part may be examined in its fresh state 
and that the other be put in absolute alcohol or in another fixing fluid 
(page 8) and prepared for finer sections. Curetted particles, on the con- 
trary, may be best put immediately into absolute alcohol and the ex- 
amination of fresh specimens may be dispensed with. This should be 
the case only when large quantities are not at our disposal, for such an 
examination discloses much to us which cannot be seen in hardened 
sections. 

1. EXAI\IINATION OF FRESH SPECIMENS. 

The fresh specimen should be put at once in the so-called "physio- 
logical salt solution" (0.75 per cent), in which the indi^ddual elements 
are perfectly preserved in their original form. They may then be ex- 



EXAMINATION OF FRESH SPECIMENS. 



amined as teased specimens or in sections cut by the freezing microtome. 
The latter method is most suited to our purpose, as the relation of the 
various structures to one another is not changed, and it permits of a 
correct judgment of the condition before us. By teasing the specimens 
we isolate the several elements from each other, and it is impossible to 
decide whether the surface epithelium sends processes into the tissue 
or whether we are concerned with a simple hyperplastic or a destructive 
process — points of decisive value in making a diagnosis. 

Formerly fine sections were made with scissors or razor. These 
methods are of no value in the case of such material as is at our dis- 
posal, because the fixing of the specimen in liver or in some other sub- 




FlGURE 2. TrANSFEREING THE SECTION TO THE SLIDE WITH A GLASS NeBDLB. 

(After 0. Israel.) 

stance destroys the tender epithelium upon the surface as well as the 
glandular formations. 

Therefore it is best to cut the fresh specimen with the freezing 
microtome, but not into too fine pieces; very thin pieces usually tear 
during subsequent manipulation. Each section must be removed from 
the blade of the knife with a fine camel's-hair brush and placed in a 
bowl of distilled water, thereby avoiding the air bubbles which rise 
to the surface on thawing of the sections, and which often adhere to 
them if ordinary salt solution or glycerin be used. To prevent tearing 
of the sections on transmission to the slide, it is better to push the slide 
under the section as it swims in the fluid, holding it gently with a glass 
rod (Fig. 2). 



EXAMINATION OF FRESH SPECIMENS. 7 

After spreading the section carefully upon the slide it is covered 
with a fine cover-glass. The latter should be grasped at one edge with 
a pincers, and the other side should be brought at an acute angle upon 
the fluid covering the surface of the slide, and gradually released. The 
superfluous fluid is removed with blotting paper. The fresh section 
is then ready for examination and may be studied in its unchanged 
form with a high or low power. When dealing with unstained sections 
the slide should be placed upon a dark under-layer. This simple pro- 
cedure greatly aids the manipulation of unstained sections. 

The examination of such specimens has various and often important 
advantages over the examination of specimens changed by hardening. 
Only in fresh cuts do we see the cells as they were during life, and 
the amount of fat, as well as any existing degenerations, may be de- 
termined. 

In addition, various micro-chemical reactions may be viewed — a step 
which should not be undervalued, for it sometimes gives us important 
information. To make a section more transparent, Ave may add under 
the edge of the cover-glass a drop of diluted acetic acid (two to three per 
cent). A bit of blotting paper put on the other side of the cover-glass 
causes the acetic acid to penetrate the specimen quickly. In this way 
rather thick sections may be so cleared up that a positive diagnosis may 
be made. Alcohol and chloroform or ether may be put under the cover- 
glass, if it is desired to remove the fat elements. 

To prove the presence of elastic fibres, caustic soda in a one to 
three per cent solution may be used. In this way a marked swelling 
of the albuminates, of the lime-producing substances, and of the con- 
tractile elements of the smooth and striated muscles and of the nuclei is 
produced; also horny substance becomes quite transparent. An es- 
pecially valuable result is obtained by a thirty-three per cent solution 
of caustic potash. In this most of the elements are preserved, 
while the cement substance is dissolved. If a piece of a uterine myoma 
be put for a few minutes in this solution, it separates under the needle, 
almost of itself, into the individual cell fibres. Ked blood cells preserve 
their form well in this solution (Friedlander). 

Bleedings into tissues or a plethora of the blood vessels can in no 
way be so well observed as in fresh specimens. These may be perma- 
nently preserved if the water or common salt solution be replaced by 
glycerin or by a fifty-five per cent solution of potassium acetate. The 
latter is preferable, because in glycerin the sections become so clear that 
after a time many points can no longer be observed; at the same time 
the cells after long-continued action of the glycerin change their form. 

The method recommended by Pick is the best for obtaining perma- 
nent specimens of frozen sections. It consists in the use of alum-carmin 
combined with formalin ; to the well-known alum-carmin of Grenach 
(containing four to five per cent of carmin) is added Schering's forma- 



8 FIXING THE SPECIMENS. 

lin, 10 to 100, which solution may be preserved in a dark bottle. The 
method of Pick is as follows : 

1. Preparation of the frozen section with Jung's microtome. 

2. Transfer of the section into four per cent formalin solution, )4 
minute. 

3. Formalin alum-carmin, 2 to 3 minutes. 

4. Washing in water, J^ minute. 

5. Alcohol, eighty per cent, ^ minute. 

6. Absolute alcohol, 10 seconds. 

7. Carbol-xylol, ^ minute. 

8. Canada balsam. 

Often on examining these sections we find ourselves compelled to 
make larger sections, and series of sections with differentiating stains. 
Then this simple method is no longer sufficient and the specimen 
must be made more resisting; it must be hardened and embedded in 
a firm substance which may at the same time be cut by the microtome 
knife. 

2. FIXING THE SPECIMENS. 

Fixing the tissue elements is desirable for further minute examina- 
tion. For this purpose, besides alcohol, the so-called "fixing fluids" 
may be used, of which I mention the following: 

(a) Miiller's solution (see below). 

(h) Saturated watery solution of corrosive sublimate. 

(c) Zenker's fluid (Miiller's fluid 100.0 plus bichloride 5.0. Shortly 
before using add 5.0 glacial acetic acid). 

Fixing with the bichloride requires two hours if the pieces be not 
too large; with Zenker's fluid, twenty-four hours. Before the pieces, 
after being fixed, are put into alcohol, they must be washed thoroughly 
in running water for at least twenty-four hours. 

(d) Flemming's solution (acetic acid 25.0; chromic acid, 3.75; osmic 
acid, 2.0; distilled water to 500). 

Specimens cleansed of blood are put for four to six hours in this 
solution; are then soaked and preserved in alcohol (sections to be stained 
with safranin). 

3. HARDENING AND EMBEDDING THE SPECIMENS. 

With our methods of examination it is of the utmost importance 
to obtain a diagnostic result as quickly and surely as possible, the 
anatomical questions connected therewith being of secondary import- 
ance. The specimen is therefore put into absolute alcohol at once as 
mentioned above. The use at first of dilute alcohol and then of stronger 
and stronger solutions I consider, at least for our purposes, to be un- 
necessary. For preparing small pieces I use a glass cylinder six to 



EMBEDDING THE SPECIMENS. 



9 



eight centimetres high and three to five centimetres wide, with flat 
bottom and cork stopper. These may also be used in the further steps 
of preparation; the labelling of every glass should never be neglected. 
If the alcohol be removed two or three times within twenty-four hours, 
the specimen has then the necessary consistence for cutting. The 
simplest process would be to cut the piece between hardened amyloid 
liver, but this is inadvisable since the surface epithelium is easily 
■destroyed. It is of the greatest importance in our examinations to com- 
press and damage the tissues as little as possible. It is therefore most 
rational to stick the specimen upon a cork or piece of wood, which may 
be fastened in the clamp of a microtome. The specimen itself is thus 
protected from injury. For this purpose we use : 

(a) Glycerin-gelatin for Fastening the Specimen. 

After the specimen has lain for several hours in absolute alcohol it 
is pasted to the cork of the glass cylinder with glycerin-gelatin. The 
cylinder is filled with fresh absolute alcohol, and is left with the cork 
downward until the next day (Fig. 3, &). 







1 






a 6 

Figure 3. 

a, glass cylinder for preserving the specimen to be examined ; 6j the same used for 
hardening the specimen fastened to the corls. 



The specimen has then the necessary firmness for cutting with a 
microtome ; the alcohol may be renewed several times if desired, though 
this step is not necessary. 



10 FREEZING MICROTOME. 

The cork is then fastened in the microtome clamp so that the speci- 
men is not injured. The glycerin layer surrounding it prevents the 
direct contact of the knife upon its surface during the cutting. In this 
way a tender epithelium covering the surface is usually retained in toto. 

The preparation of the gelatin is simple. Ten grammes of the finest 
gelatin is put into a well-cleaned vessel and covered with water. After 
four to six hours the gelatin is sufficiently swollen, and, after pouring 
off the water, may be easily liquefied by moderate heating. While 
stirring with a glass rod ten grammes of glycerin and five drops of 
carbolic acid are added ; this mixture is left in a wide-necked vessel. 

To paste a specimen upon a cork a piece of this gelatin is taken and 
made fluid by heating. A thin layer is poured upon the surface of the 
cork, and the previously hardened specimen placed upon it and covered 
on all sides with fluid gelatin. If it is desired that no part of the upper 
layers be lost, the whole specimen may be covered with a mantle of 
gelatin, which becomes firm after a short time. The specimen is ready 
for cutting the next day if immersed in absolute alcohol. This pro- 
ceeding has the advantage that good sections may be obtained with 
rapidity, and may subsequently be stained by any desirable method. 

(b) Cutting Alcohol Specimens with the Freezing Microtome. 

Recently the following method has been recommended : After harden- 
ing small pieces for several hours in absolute alcohol, they are put for 
two hours in a four per cent solution of formalin, then placed in water 
for half an hour, after which they may be cut with a freezing micro- 
tome. Even pieces which have lain for longer periods in alcohol may, 
if put in two per cent formalin for two to six hours (according to their 
size), be cut with a freezing microtome. This method, introduced by 
Benda, has the advantage that, although the alcohol is removed, the 
fixing of the tissue is not affected. It is, however, impossible to make 
a large series of sections of specimens prepared in this manner, and it 
is frequently necessary to make a series of sections not only for finer 
anatomical examination but also to insure a positive diagnosis. We 
will discuss those methods which make this possible. 

We are concerned here with the so-called "embedding" of the speci- 
mens, i. e., their saturation with a substance at first fluid, but later 
solidifying, which adapts itself to every fold and cavity, and preserves 
their form when solidified. The most convenient and satisfactory method 
for our purpose is: 

(c) The Embedding of Specimens in Celloidin. 

The fresh specimen is put for twelve to twenty-four hours in ab- 
solute alcohol (according to its size) and for the same length of time 
in sulphuric ether. 



EMBEDDING SPECIMENS IN CELLOIDIN AND PARAFFIN. 11 

When freed from water by this means it is put into a thin liquid 
solution of celloidin. Celloidin is cut into small pieces and dissolved 
in equal parts of absolute alcohol and ether. A thin or thick solution 
may be obtained, depending upon the amount of alcohol and ether used. 
The specimen while in thin celloidin should be entirely covered by it^ 
remaining for twenty-four hours in an air-tight bottle. At the ex- 
piration of this period the specimen is placed in a thick solution of 
celloidin, a small slit being left in the covering of the vessel so that the 
alcohol and ether may evaporate very slowly. After a few hours the 
celloidin becomes cloudy and of semi-solid consistence. It is then pos- 
sible to cut out the specimen with its mantle of celloidin and to paste 
it with thick celloidin upon cork or wood, after which it remains for 
twelve hours in seventy to eighty per cent alcohol, when it has obtained 
the proper consistence for cutting. This method, with the above-men- 
tioned advantages, takes four to five days. A more troublesome method, 
but one which at times must be used, is: 

(d) The Embedding of Specimens in Paraffin. 

This method is used for our purposes only in making serial sections. 
It is better to stain such specimens in toio, but pieces too large to 
insure proper staining should not be taken. Pieces one centimetre 
wide and two centimetres thick are best; pieces more than four 
centimetres thick should never be used, if possible. The fresh specimen 
is put into dilute alcohol, which must be renewed at times until it re- 
mains perfect!}^ clear; it is then placed in the staining solution. Yery 
good results are obtained with Bohmer's hematoxylin; eosin and safra- 
nin are also suitable. The specimen, according to its thickness, remains 
two to eight days in the well-filtered solution. An over-staining is not 
to be feared; even if the external part be darkly tinged this is better 
than having the central portions unstained by too rapid methods. From 
the staining solution the specimen is put into seventy per cent alcohol, 
where it lies for twenty-four hours, being then dehydrated in absolute 
alcohol. It is then put for twelve hours in xylol to prepare it for 
saturation mth paraffin. 

The saturation mth paraffin is accomplished as follows : A mix- 
ture of xylol and paraffin, equal parts, is made b}' melting paraffin of 
a low melting point over the flame and adding an equal quantity of 
xylol. In this the specimen remains for twenty- four hours at a uniform 
temperature of 37° Centigrade, in a paraffin oven with thermostat, and 
is then put into pure paraffin at a constant temperature of 48° to 50° 
Centigrade. The paraffin is then permitted to solidify at room tem- 
perature, and the paraffin block, containing the specimen and cut diOvm. 
to proper size, is fastened with paraffin upon a cork or wood and is then 
ready for cutting. Such blocks may be preserved in a dry condition 
as long as is desired. If these directions are followed closely a complete 



12 CUTTING THE SPECIMENS. 

series of sections may be cut. The individual sections are thinner than 
those obtained by any other method. Of course, as in all technical pro- 
cesses, practice is required, but patience should not be lost if first at- 
tempts fail. 

The methods with which the specimens prepared in these different 
ways should be cut with a microtome will be discussed in the next 
chapter. 

4. CUTTING HARDENED OR EMBEDDED SPECIMENS WITH 

A MICROTOME. 

In cutting, the microtome knife is so placed that its entire cutting 
edge may be used. It must therefore form a most acute angle with the 
specimen. The blade of the knife and the specimen itself must be con- 
stantly moistened; only frozen and paraffin specimens are cut dry with 
the knife in a transverse position. The body which holds the knife 
must be moved evenly and not too quickly; the runners must be well 
oiled. The thickness of each section should always be alike; sections 
of fifteen to twenty microns are as a rule sufficient for our purpose. One 
should not believe that the thinnest sections always reveal the most. 
Only those specimens hardened in alcohol and embedded in gelatin or 
those held between bits of liver should be moistened with absolute 
alcohol ; those embedded in celloidin should be moistened with seventy to 
eighty per cent alcohol. 

As numerous sections one after another are generally made, a small 
bowl filled with dilute or absolute alcohol should be placed on a dark 
under-layer next to the microtome, and the sections should be trans- 
ferred from the blade to the solution with a fine camel's-hair brush. 
The cuts are naturally much shrivelled by the alcohol and should be 
placed in water for several minutes before staining. They then spread 
out, lose their folds, and regain very nearly their original form. They 
are then transferred to the staining fluid by means of a spatula. 

A very different technique is required for cutting specimens em- 
bedded in paraffin. These sections are generally quite thin and cannot, 
as in other methods, be transferred from one vessel to another, therefore 
all the manipulations must be accomplished on the glass slide. I, as a 
rule, make use of the following method : In a wide-necked bottle absolute 
alcohol is poured over collodion, covering it entirely. Of this solution, 
which keeps well if corked thoroughly, one drop is placed upon the 
slide, and the section, transferred from the knife with a soft brush, is 
pressed down upon it firmly with filter paper. In this way the section 
is firmly fixed and the superfluous fluid is at the same time removed. 
In the same manner the second and the following sections are placed 
in a row, the sign of an arrow being made upon the slide to show in 
which direction the series runs. To give the whole a pleasing appear- 
ance a piece of white paper with uniform fields marked upon it is put 



STAINIXG THE SECTIONS. 13 

under the glass slide, and the sections are attached to the slide at equal 
distances from each other. 

"When a glass slide is covered ^^dth ten to twenty sections, according 
to the size of the specimen, the paraffin is dissolved by pouring xylol 
over the whole slide, making each cut transparent. The superfluous 
xylol is removed by pouring it into a small bowl (this xylol can be used 
several times}. The sections are then covered with xylol and Canada 
balsam, equal parts. ^ TVhen putting on the cover-glass care should be 
taken to avoid air bubbles, which are often annoying. One should not 
be sparing with the Canada balsam, for whatever runs over may be 
easily removed. The cover- glass should be held at one side with a forceps 
and should be lowered slowly upon the balsam. The large cover-glasses 
which are used should be well cut ; it is necessary to observe that they are 
not too thick, for if they are it is difficult to use poAverful magnification. 

We have here discussed purposely only the cutting of hardened 
specimens with a microtome ; for, with the small amount of material 
generally at our disposal, sections made with a razor, even if skilfully 
done, give us little aid and waste our scanty material. In addition the 
sections are thicker than those made with a microtome, and errors in 
judging the microscopical picture are easily made — viz., an epithelial 
growth in glands may be diagnosed when in reality it is simply an 
illusion due to the thickness of the sections. At any rate, serial sections 
can never be made with the hand. 

5. STAINING THE SECTIONS. 

It is not our purpose to consider here all the methods of staining 
which have been used since the introduction of this procedure. For 
our purpose good results are obtained with very simple stains. I use 
exclusively hematoxylin or picrolithiocarmin (Orth), but examine 
every section, and this is decidedly to be recommended, first unstained, 
in water or glycerin. 

(a) Picrolithiocarmin. 

This exceedingly good contrasting stain, introduced by Orth, is pre- 
pared as follows: 

Solution I. : A cold saturated solution of lithium carbonate, in which 
carmin powder dissolves in any desirable amount — 2.5 grammes of 
powder to 100 grammes of lithium carbonate solution is a combination 
which may be recommended ; lithiocarmin. 

Solution II : Saturated solution of picric acid. 

One part of Solution I. to two parts of Solution II. gives a good 
picrolithiocarmin solution. 

^ If the sections are not previously stained, this may he done on the slide, 
all the sections being stained at one time. Xylol, absolute alcohol, 96 per cent 
alcohol, water, stain, water, alcohol, xylol, Canada balsam. 



14 STAINING THE SECTIONS. 

This stain is best used for only those specimens hardened in alcohol. 
Those specimens prepared in glycerin- gelatin stain a deep red. 

The section, after it has been spread out in water, should be placed 
in this stain with a spatula for five to ten minutes, when it is then 
deeply stained. A special advantage of this stain is that even if the 
section remains in it for a longer period it is not over-stained. The sec- 
tion is then put for one to two minutes in alcohol containing hydro- 
chloric acid (one part hydrochloric acid to one hundred parts of seventy 
per cent alcohol), and is then washed in dilute alcohol and dehydrated 
in absolute alcohol. The specimen is then made clearer in oil of cloves, 
oil of bergamot, or in xylol, and then transferred by a spatula to the 
slide and spread out so that no folds are present. After removing the 
superfluous oil it is mounted in Canada balsam. The latter may be 
kept of a proper consistence by the aid of chloroform or xylol. 

By this method the nuclei become a deep red while the protoplasm is 
■scarcely stained. Horny cells, as well as fibrin, hyaline substances, and 
red blood corpuscles, take on a yellow color. The nuclei of squamous 
epithelium become a pale pink, fibrillar connective tissue remains 
undyed, so that the whole makes a clear picture of the specimen thus 
stained. 

The specimens embedded in celloidin do not give as good results by 
this method as with hematoxylin, which I prefer for that reason. 

(b) Hematoxylin. 

To prepare this stain, if not desirous of using the purchasable 
Delafield's hematoxylin, use the following method: One gramme of 
hematoxylin is dissolved in 30 grammes of absolute alcohol. A solution 
of powdered alum is prepared, 0.5 to 1 gramme of alum in 30 cubic centi- 
metres of distilled water. Into this is shaken drop by drop the alcoholic 
solution of hematoxylin until the fluid takes on a deep violet color. It 
is then left for several days in an uncovered wide-necked vessel, when 
it becomes darker. Before using it must be carefully filtered. 

It should be a general rule to filter all staining solutions before 
use. For this purpose I have used for years bottles with glass funnels. 
The filter paper lining the funnel serves to close the bottle, so that the 
solution is quite protected from impurities. 

Sections embedded in celloidin remain longer than the ordinary 
alcohol sections in this solution (ten to twenty minutes or more, ac- 
cording to size and thickness), and are then placed for a short time in 
alcohol containing hydrochloric acid until they begin to assume a red 
tint, and are then placed in seventy per cent alcohol. It is well to 
leave the sections then in absolute alcohol until the mantle of celloidin 
begins to curl. Care must be taken that the alcohol does not dissolve 
all the celloidin, for then very fine sections easily fall to pieces. The 
section is then made transparent in oil of bergamot or in xylol. If at 



STAINING OF ELASTIC FIBRES. 15 

this stage the celloidin mantle becomes milky or cloudy, the specimen 
must be put again into absolute alcohol until the cloudiness has dis- 
appeared. 

The section is then put with a spatula upon the slide and mounted 
in xylol-Canada balsam, after removing the oil with filter paper. 

The advantage of this method is the splendid staining of the nuclei. 
The protoplasm is faintly stained, the celloidin not at all. If it be de- 
sired to stain the protoplasm also, eosin^ may be used later, which, with 
hematoxylin, gives very clear pictures. Such a double method is not ab- 
solutely necessary for our diagnostic purposes. When one has gained 
stifiicient technique with both of the above-mentioned methods other 
procedures will scarcely be needed. , 

(c) Staining of Elastic Fibres. 

Recently the staining of elastic fibres has been brought into promi- 
nence (Meissner). Since this is of importance in the case of the female 
genitalia, and especially in the case of malignant tumors, these methods 
will be mentioned: 

1. Taenzer's Orcein Stain. 

The sections are taken from water and put for six to twelve hours 
or longer in orcein solution (Griibler's orcein 0.5, alcohol 40.0, aq. 
dest. 20.0, acid, hydrochlor. gtt. xx.), and are then placed for a few 
seconds in hydrochloric acid alcohol (acid muriatic 0.1, ninety- five per 
cent alcohol 20.0, aq. dest. 5.0), where they become differentiated, and 
are then, after they have taken on a wine-red color, washed in water. 
Then dehydration in absolute alcohol five to ten minutes. They are then 
cleared in oil and mounted in Canada balsam. 

The elastic fibres appear an intense red upon a pale pink back- 
ground. 

2. Weigert's Fuclisin-Resorcin Stain. 

Staining solution. — Of a resorcin-fuchsin mixture (resorcin 2.0, 
fuchsin 1.0, distilled water ad 100.0) 200 c.c. are put into a porcelain 
bowl and brought to boiling; then 25 c.c. ferri liq. sesquichlor. (Ger- 
man Pharmacopeia) are added and the whole is alloAved to boil, 
with stirring, two to five minutes more. A muddy deposit is 
formed. The mass is allowed to cool (it need not get quite cold) and is 
then filtered. What runs through the filter is thrown away; the deposit 
is left upon the filter until all the water has dripped off. The filter is 
then taken off the funnel and put with the deposit in a bowl, in which 
it is boiled, under constant stirring, with 200 c.c. of ninety- four per cent 
alcohol. During the boiling the filter paper is removed. The solution is 

1 A concentrated alcoholic solution of eosin is put drop by drop into 96 per 
cent or absolute alcohol till the latter assumes a rose-red color. In this mixture 
the specimen is left from a few minutes to several hours. In a watery mixture 
of eosin of like strength specimens remain only a few minutes. 



16 STAINING OF MICRO-ORGANISMS. 

then permitted to cool and is filtered, and the filtrate is, by the addition 
of further alcohol, brought to 200 c.c. After adding 4 c.c. of hydro- 
chloric acid the solution is ready for use. 

Staining. — In this solution the sections are placed for twenty minutes 
to one hour, washed in alcohol and cleared in xylol (not in oil of cloves), 
Carhol-xylol and aniline oil with xylol cannot be used. 

After staining, the elastic fibres appear dark blue, almost black, 
on a quite light background. The nuclei may be stained then with any 
good carmin. Washing in HCl-alcohol does no harm. 

The unstained sections may be preserved in one of the above-illus- 
trated glass cylinders in absolute or dilute alcohol, depending upon 
their hardening in alcohol or their embedding in celloidin; for it is 
often necessary after some time to again examine a specimen for one 
reason or another. , 

6. STAINING OF MICRO-ORGANISMS. 

Of the micro-organisms found in the female genital canal, the gono- 
coccus and the tubercle bacillus are of special practical importance for 
our diagnostic purposes. These are sought for either in the secretion or 
in sections. In the former case, glass slide or cover-glass specimens of 
the secretion are made by spreading it on and letting it dry. These speci- 
mens are first allowed to dry in the air, and are then carefully drawn 
several times through a flame. They are then ready for staining, and 
there is no fear that during the subsequent manipulations the secretion 
will be washed off. 

(a) The Gonococcus. 

(a) Dry Cover-Glass Specimens. 

In general the following simple proceeding suffices: 

1. Covering the dry specimen with a watery concentrated methyl 
blue solution (Unna). 

2. Heating till it steams. 

3. Washing in water. 

4. Drying with filter paper. 

5. Embedding in Canada balsam. 

In this way the gonococci as well as the other cocci are stained a deep 
blue. The gonococci are characterized by the fact that, lying in pairs 
next to each other ("biscuit-shaped"), they appear mostly in small 
groups inside the protoplasm of the pus cells. Sometimes they lie out- 
side of the cells and may then be mistaken for other cocci, if it were 
not possible to use a method of differentiation. This method we possess 
in the shape of Gram's decolorizing method with Lugol's solution, by 
which the gonococci are decolorized while the other pathogenic and non- 
pathogenic cocci retain their stains. By subsequently or previously 



STAINING OF MICRO-ORGxiNISMS. 17 

staining with a contrasting color the gonococci are then differently 
stained. 

Gram's MetJiod. 

The dry cover-glass or slide specimen is stained with picrocarmin 
or with thin fuchsin solution, washed in water, and dried. It is then 
stained for one-half minute with Ehrlich's aniline water-gentian violet 
solution, and then (without washing) for one minute with Lugol's solu- 
tion (1 iodine, 2 potassium iodide, 300 water), and then moved in 
alcohol until maximum decolorization is obtained. The specimen is 
washed in running water, dried, and mounted in xylol- Canada balsam 
(Giinther). The gonococci are found to be red, while the other cocci 
are stained blue. 

(6) Cut Sections. 

To find the gonococci in sections is much more difficult than in dry 
specimens. Practice is necessary to obtain good stains. The method of 
Wertheim is as follows : 

1. Sections are put in aniline water-gentian violet 3 to 5 minutes 
(not longer, for then the celloidin is affected). 

2. Lugol's solution, about 1 minute. 

3. Ninety-five per cent alcohol for decolorizing (this should not be 
complete; the section must still have a distinctly violet color). 

4. Watery methyl blue solution, for a few minutes. 

5. Absolute alcohol, ^ to 1 minute. 

6. Oil of bergamot. 

7. Canada balsam. 

The most essential and difficult point is to observe the proper limit 
when removing the methyl blue by alcohol. If this process be too short, 
then the gonococci are not distinctly seen on the too dark background; 
if too long, then the gonococci are also decolorized. 

(b) Tubercle Bacilli. 
The staining is best managed by means of 

(a) Gahhet's Quick-Staining MetJiod. 

1. Dry specimen is stained ten minutes in carbol- fuchsin (fuchsin 
1.0; alcohol 10.0; acid, carbol. 5.0; aq. dest. 100.0). 

2. Washing in water. 

3. Drying with filter paper. 

4. Sulphuric acid-methyl blue solution (methyl blue 2.0 ; acid, sulph. 
25.0; aq. dest. 100.0) five minutes. 

5. Washing in water. 

6. Drying with filter paper. If red areas are still present the speci- 
men must be put again for several minutes in the sulphuric acid-methyl 

2 



18 



CONSERVING THE MATERIAL. 



blue solution. After drying, the specimen must have a light blue ap- 
pearance. 

7. Canada balsam. 

The tubercle bacilli are then red; everything else is stained blue. 

(5) Sections. 

For staining sections we use either warm carbol-fuchsin solution 
(the section is put into the staining fluid, which has been heated and re- 
moved from the flame), or the section is put into the cold solution for 
twenty-four hours. After treatment with sulphuric acid-methyl blue 
solution the section is dehydrated in alcohol, cleared in xylol, and 
mounted in Canada balsam. 



III. THE MANAGEMENT OF MATERIAL OBTAINED BY 
LAPAROTOMY OR AUTOPSY. 

The specimen, concerning which in its fresh state all necessary notes 
as to size, color, and consistence are made, must be cleansed under run- 
ning water of gross impurities and is then put in 

1. Seventy per cent Alcohol. 

This is renewed regularly until it remains perfectly clear. Care 
should be taken that the fluid is always a few centimetres above the 
specimen, as it otherwise easily dries up. 

Alcohol is without doubt the most convenient and best preserving 
material for specimens which must later be examined microscopically. 
At times we are forced to use 

2. Milller's Fluid, 

when, for instance, it is necessary to examine placentae and we de- 
sire to preserve the blood corpuscles in an unchanged condition. 
Miiller's fluid is composed of 

Potassium bichromate 2.0 

Sodium sulphate 1.0 

Distilled water , 100.0 

How long the specimen should remain in this fluid depends upon 
its size ; an entire uterus, for instance, requires about eight weeks. After 
twenty-four hours the fluid, as a rule, becomes cloudy and should be 
renewed. If the specimen is completely saturated it is then kept in eighty 
per cent alcohol, after having been flrst washed under running water for 
several hours. If it is desired to fix other form elements (division of 
nuclei, etc.), small dice-shaped pieces must be cut out of the specimen 
and put into suitable fixing fluids (see above). 



COXSERYIXG THE MATERIAL. 19 

In recent years, for fixing and preserving specimens; great import- 
ance has been attaclied to 

3. Formalin. 

Commercial formalin is a forty per cent solution of formaldehyde. 
As a rule a four per cent aqueous solution of formalin is used. In this 
the specimens remain fo^ twenty-four hours and are then put. after 
thorough washing, into alcohol of increasing concentration. Formalin 
is at the same time a fixing and a hardening fluid, and has. in addition, 
the power of preserving the natural color of the specimen. Therefore 
in place of alcohol the specimens may be preserved in a two per cent 
solution of formalin. 

In preparing the specimen for microscopical examination everything 
depends upon its character. Definite rules cannot be made. The speci- 
men should be preserved macroscopically as far as possible. Large sec- 
tions which give a general idea of relations are of special value for 
judging many anatomical processes. For instance, it is not difficult to 
make sections through the entire length of the uterus. With practice 
these may be made so thin that they may be examined with a high- 
power lens. Good results in such cases depend upon careful embedding 
and upon a large, sharp knife which does not feather. For embedding 
such large specimens, which, however, should not be more than 1 cm. 
in thickness, celloidin gives the best results. 

The specimen, well hardened in absolute alcohol, is put for several 
days in sulphuric ether and then for three to six days in very thin cel- 
loidin in an airtight jar. It is then placed for two to three days in 
thick celloidin. likewise under an airtight cover, which at the expiration 
of this time is opened a very little so that the ether evaporates slowly. 
When the celloidin solidifies, the specimen, vriih its mantle of celloidin, 
is fastened upon a suitable block and is put into seventy per cent alcohol. 
In twenty-four hours the specimen is ready for cutting. 

While cutting the large specimen it must be constantly moistened by 
a flow of seventh' per cent alcohol. For this purpose a special supply ap- 
paratus is used I'see appendix). The blade of the knife must also be 
constantlv moistened. Even in these large sections the knife must be 
drawn through evenly and not too quicldy, and the section must be 
smoothed out with a brush. Sections of twenty to thirty microns are 
quite suitable. 

In further manipulations large glasses like watch glasses are used. 
The individual steps in the process of staining, washing, and clearing 
are the same as already described, but demand, on account of the size of 
the specimen, much more time. It is advisable, if sufficient material is at 
hand, to make sections vertical as well as parallel to the surface, for 
just such sections often give information not to be obtained in any other 
wav. 



20 INSTRUMEXTARIUM. 

IV. APPENDIX TO PART I. 

rKSTRTOIENTARimi. 

1. Needle holder. The best are those in which the needles may be 
changed. Wooden handles are better than bone. 

2. Spatula, of various sizes,, with very thin, supple blades. 

3. Brushes, as soft as possible and of various sizes. 

4. Scissors, large and small, straight and bent like Cooper's scissors. 

5. Forceps — those made by Katsch, in Munich, are very good, and are 
recommended by Waldeyer for practice in preparing specimens. In 
Berlin they may be procured of Thamm and Schmidt. 

6. Knife (razor'' hollowed out on one side only. A double knife is 
unnecessary. 

7. Microtome. The choice of a microtome is not easy, as on its quality 
depends the character of the sections. If a large model can be obtained 
this is advisable, for this suffices for all sections, even the smallest. The 
smaller instruments, on the contrary, do not suffice for the larger sections. 

A freezing apparatus is very desirable for our purposes. Jung in 
Heidelberg and Schwarze in Leipzig furnish this apparatus suited to 
a microtome. It is advisable, however, to procure a special freezing 
microtome for preparing frozen sections. Such a microtome is no dearer 
than the other accessory apparatus and possesses many advantages. For 
this latter purpose the lever microtome of Jung is to be recommended. 
The short knives are better able to stand the wear and tear than the large 
ones of the other apparatus, which are intended to cut only embedded 
specimens. 

For general work I have used for years the large model of Jung. A 
smaller one is sufficient for diagnostic purposes only, and the difference 
in cost is so small that it is better to select at once the larger model, for 
after a short acquaintance with the smaller size one finds the larger 
quite necessary. 

In the instrument of Jung the specimen is lifted by forward move- 
ment on an oblique plane. The microtome screw is excellently made, the 
knife carrier is stable, the clamp holding the specimen may be fixed in 
any position, the loiife is perfect, so that with this instrument perfect 
sections, from the smallest to the largest size, can be made. The knife 
carrier is moved either with the hand or with the lever. I prefer to use 
the hand. For the large specimens special blocks with grooved surfaces 
should be obtained and made to fit in the specimen clamp. The small- 
est specimens are fastened to cork and then grasped by the clamp. In 
cutting, the' specimens must be moistened with alcohol by a brush; for 
the larger specimens an apparatus with a constant flow of alcohol is in- 
dispensable. Of knives, two small and two large ones must be selected. 



INSTRUMENTARIUM. 21 

They should be carefully dried with a soft cloth and stropped before 
using, but not too often and only on a soft leather surface. 

The runners on which the knife carrier rests must be oiled with bone- 
oil, so that only slight force is necessary to make it pass along the entire 
length of the instrument. After use the microtome should be carefully 
cleansed of oil and alcohol. 

8. An apparatus which gives a constant supply of alcohol, drop by 
drop. 

9. A small paraffin oven with thermostat. 

10. Glass vessels of various sizes, cylinders for the specimens, etc. 



PART II. 
DIAGNOSIS. 



To form an opinion of pathological changes it is necessary to have 
an exact knowledge of normal conditions. This is the more important 
since the female sexual organs, even under normal conditions, are sub- 
ject to changes in their anatomical character. For instance, what is nor- 
mal in a woman who has passed the climacterium may be pathological 
in a patient in the prime of life. In the same way conditions during and 
after pregnancy, before and after menstruation, must be viewed from a 
different standpoint in the case of the uterus of a nullipara or primi- 
para and in that of a multipara. In the following description of normal 
conditions it must be clearly understood what is meant by the word 
* 'normal." As is customary, we accept as normal types those anatomical 
states in which the organs are found between two menstrual periods. 
The different variations from the normal which must be considered in 
diagnosis will be discussed wherever necessary. 



1. VULVA. 

1. NOKMAL ANATO]\IY. 



Under vulva we understand the labia majora, the labia minora, the 
clitoris, the glands of Bartholini, and the corpus cavernosum of the 
urethra. 

The labia majora are puffy prominences of the skin, which under 
normal conditions meet in the median line. Their microscopical struc- 
ture corresponds exactly to that of the external skin. Under many layers 
of squamous epithelium, which cover the subcutaneous tissue and the 
papillae, lie sebaceous and sweat glands, hair, etc. The underlying con- 
nective tissue is loose and wavy ; between its bundles lie blood vessels and 
wide l;vTnph spaces; in the deeper layers an abundance of fat tissue is 
present. 

The surface of the labia minora (nymphae), which are covered by the 
labia majora, has the character of the skin in general and shows seba- 
ceous glands, but has the appearance of a mucous membrane, since it is 
moistened by the secretion of the vagina and of the glands of Bartholini. 
The anatomical structure is the same; yet hair is missing here. At the 



PATHOLOGICAL ANATOMY OF THE YUI.YX. 23 

vaginal inlet, in the virgo intacta, a semicircular wall is formed by the 
hymen, so that in this way a boundary is placed between the external 
and internal genitalia. 

The hymen is a crescent-shaped membrane. It is covered on its inner 
and outer surfaces by stratified, squamous epithelium, beneath which 
lies connective tissue rich in nuclei. In the papillae of the hymen are 
nerve end bulbs, just as in the external skin. 

Just in front of the h^Tnen, in the so-called vestibule, open two large 
mucous glands, the so-called glands of Bartholini. 

2. PATHOLOGICAL ANATOMY. 

( A ) IXFLAMM ATIOXS. 

The inflammations of the ^ailva affect chiefly the smaller labia and 
the vestibule, and are most frequently gonorrheal. Such inflammations 
are usually attended by a profuse purulent secretion. In this secretion 
gonococci are usually found. The smaller lips are then very red and 
edematous. Frequently small superficial excoriations are present and 
bleed easily. The microscopical picture shows the subepithelial tissue 
to be very vascular and to contain solid groups of round cells. These 
penetrate the epithelium, loosen it, and thus prepare it for shedding. 
The gonococci also penetrate the epithelial layer and may be found in 
sections of the underlying tissue. 

Secondary inflammations of the vulva occur especially in septic affec- 
tions in childbed. 

(b) Ulcer atioxs. 

The most important and most frequent ulcerations are sypliilific. 
These are not to be distinguished microscopically from simple ulcei^. 
The edge of these usually round ulcers is hard. In connection with such 
ulcers the labia majora may become edematous and firm. Much less fre- 
quent are the tuhercular ulcers (lupus ^ailvae). These are to be diag- 
nosed microscopically through the presence of tubercles containing giant 
cells. It is rarely possible to find tubercle bacilli in them. 

( c ) Atrophy. 

In addition to the atrophy of the external genitalia occurring nor- 
mally in advanced age through disappearance of adipose tissue, there is 
observed, in some instances, a peculiar atrophic condition which is called 
kraurosis vulv^. 

As a result of the thorough microscopical iuA^estigations of Orthmann 
and Peter in the clinic of Martin, this process must be considered a 
chronic inflammatory hyperplasia of the connective tissue with a ten- 
dency to cicatricial contraction, inflammatory edema of the superficial 
layers of the corium and the epidermis, and degeneration of the elastic 



24 PATHOLOGICAL AXATOMT OF THE VULVA. 

tissue. This condition is often connected witli so-called pruritus vulvae, 
wMeli shows itself clinically as an unbearable itching. In the latter no 
anatomical changes may be found; it may be that it is an affection of the 
nerve ends which is as yet not recognized. The pathological changes 
connected therewith are to be considered as secondary and caused by 
scratc hin g. These changes inchide a small- celled innltration of the 
upper layers under the squamous epithelium, which is in spots hyper- 
trophic. 

(D; HtPERTEOPHT. 

Hypertrophies involve either the epithelium or the connective tissue. 
The former occur by far the more frequently. 

(a) EpithelMl Hypertropliies, Pointed Condylomata (Condylomata 

AcTirrs'ATA). 

The pointed condylomata are growths of the squamous epithelium 
and the papilhe. which rise above the surface in a wait-like manner, and 
which, on account of the many depressions between the elevations, give 
the growth a cauliflower appearance. As a rule, these condylomata are 
small, the size of a pea or a bean. Through coalescence of a large num- 
ber of such formations larare tumoi*s of the vulva mav result. Because 
of their uneven surface thev mav be easilv taken for carcinomata. Here 
the microscopical examination is decisive, for it is seen that these epithe- 
lial growths are confined solely to the surface: they are simply eleva- 
tions and thickenings of epithelium which do not grow into the deeper 
tissues and destrov them. In lonsr-standingr condvlomata the surface 
may become ulcerated, and is then covered with a greasy, purulent layer, 
which makes a confusion with carcinoma still easier. The underlying 
connective tissue is found in an inflammatory state, showing small-celled 
infiltration and numerous new formations and ramifications of the 
papiUse. 

Most frequently these pointed condylomata develop in connection 
with a gonorrheal vulvitis. It must be positively understood that other 
inflammatory or chronic irritations may also cause the formation of 
condylomata. Such epithelial growths may develop especially as a re- 
sult of irritations present during pregnancy. During this time unusu- 
allv larsre tumors mav be formed. 

"^Vhether condylomata are of gonorrheal origin or not can be deter- 
mined only by showing the presence of gonococci. A small quantity of 
the secretion is spread upon a glass slide with a previously heated 
platinum needle, and. after being dried in the air. should be stained 
with a watery solution of methylene blue. For this purpose I have found 
the polychrome methylene blue of Unna very serviceable. A few minutes 
suffice for the .staining: the slide is then washed with water and dried 
with filter paper, and can be examined in oil immersion even without a 



PATHOLOGICAL AXATOMT OF THE VULVA. 25 

cover glass. The gonococci show the well-known biscuit form through 
the apposition of cocci in pairs, and lie generally in the cell protoplasm. 
As a rule several nuclei are found in the pus cells. 

If a positive diagnosis is to be made and confusion of the gonococci 
with other cocci is to be avoided, the specimen should be decolorized in 
the manner described above, according to the method of G-ram. In this 
way the gonococci lose their stain while the other cocci retain theirs. It 
is then only necessary to employ a contrast stain, viz.. Bismarck brown, 
to be enabled to see the gonococci colored brown in contrast to the other 
cocci stained blue (see page 17). 

. (&) Connective-Tissue Hypertrophy. 

In this category must be considered elephantiasis yuijVM. This 
occurs unilaterally or bilaterally and forms large nodulated tumors of 
semi-solid consistence. Microscopically there is found a considerable in- 
crease of the connective-tissue stroma, with numerous dilated lymph ves- 
sels filled ^vith lymph cells. An increase of the elastic tissue likewise 
takes place. Some authors describe an hypertrophy of the epithelium. 
In a case observed by me and thoroughly examined, the microscope 
showed the epithelium to be astonishingly thin — a condition caused, no 
doubt, by the great stretching and gTowth of the underlying tissue, with 
which the growth of the surface epithelium did not keep pace. 

(e) Neoplasms. 

Epithelial growths and growths of the connective- tissue tissues may 
be distinguished. The former are observed more frequently than the 
latter. Both, however, are rare. 

(a) Epithelial Neoplasms. 

< ex) Carcinoma. 

Carcinomata of the vulva always originate from the squamous 
epithelium of the surface. Groups of epithelial-like cells force their way 
into the deeper structures and destroy the tissues originally present. 
The carcinomata correspond in structure to the typical carcinomata of 
the skin. Therefore we find here, in the carcinoma nests, central hornifi- 
cation, the so-called carcinomatous pearls. In one case operated upon by 
me carcinomatous thrombi were found at a very laree number of 
points in the blood vessels, whereby rapid propagation was naturally 
aided. This extension occurs not onlv throush the blood vessels, but 
especially through the lymph channels. One finds, therefore, relatively 
early metastases in the inguinal glands. These also show the structure 
of squamous epithelium carcinoma. 

Most of these carcinomata begin at the outer surface of the vulva. In 
rare cases primary carcinomata of the clitoris occur. 



26 PATHOLOGICAL ANATOMY OF THE VULVA. 

(y5) Cysts of the Vulva. 

The cysts occurring on the large and small labia are retention cysts 
of the sebaceous glands. Furthermore cysts of the glands of Bartholini, 
especially of their excretory canal, occur. These result chiefly in connec- 
tion with an inflammatory process and possess, in case of simple inflam- 
mation, thin fluid contents. If, however, the cause of infection is gon- 
orrheal, there results an obstruction in the excretory duct and an abscess 
is formed. In the pus removed from these cysts gonococci are usually 
found. 

Finally, cysts of the hymen have been described. These are lined 
either mth squamous or ciliated or simple cylindrical epithelium. 
What the origin of these cysts may be has not been established with ab- 
solute certainty (see Part III.). 

(&) Neoplasms of the Connective Tissues. 

Of these only fihromata may be mentioned, for they are the most 
frequent and may reach a very great size. Furthermore, in individual 
but very rare cases myomata, lipomata, myxomata, etc., have been ob- 
served. All these tumors of the vulva resemble in their structure the 
same tumor forms occurring in other parts of the body, and offer no diffi- 
culties in the way of diagnosis. Sarcomata are found here rarely, mostly 
as mixed tumors, such as fibro- and myxosarcomata, and more fre- 
quently melanosarcomata. 



II. VAGINA. 

1. NORMAL ANATOMY. 



The vaginal mucous membrane does not line this canal with an even 
surface, but forms numerous elevations and depressions (rugae and col- 
umns rugarum). 

The surface epithelium is a stratified squamous epithelium, into 
which the papillae of the underlying tissue project. The stroma is con- 
nective tissue containing few cells, in which no glands are present. In 
the deeper layers are muscle fibres and fat tissue. Some authors describe 
glands, lined with cylindrical or ciliated epithelium, as normal constitu- 
ents of the mucous membrane. According to recent and harmonious 
opinions it must be concluded that such a condition is rather patho- 
logical. I have never found glands in the normal mucous membrane of 
the vagina. Occasionally in the deep grooves of the lining membrane 
cylindrical or ciliated epithelium may be found instead of squamous 
epithelium. Such conditions are doubtless the result of embryonal dis- 
turbances, for originally the entire genital tract is covered or lined with 
cylindrical epithelium (see Part III.). 



PATHOLOGICAL ANATOMY OF THE VAGINA. 27 

2. PATHOLOGICAL ANATOMY. 

(a) Inflammations. 

Practically, the most important is the inflammation which occurs 
in gonorrhea, and which causes the mucous membrane to be covered with 
small nodules — granular vaginitis. Microscopically this condition shows 
a marked infiltration of lymphoid cells, limited entirely to the super- 
ficial layers. These cells penetrate the epithelium and (feause it to be 
loosened and thrown off. At the height of these nodular elevations the 
epithelium is very thin and may be easily lifted off. Then erosions re- 
sult. In the secretion desquamated epithelial cells and pus cells with 
gonococci are found. 

A different but rare form of inflanunation is cystic vaginal hyper- 
plasia, also called emphysema of the vagina or kolpitis emphysematosa. 
In this condition cysts are formed which lie close under the sur- 
face, and are filled with gas. This consists partly of air, partly of 
trimethylamin. The mucous membrane is very red. Microscopically a 
decided small-celled infiltration of the stroma is found. This affection 
is observed during pregnancy; as to its cause nothing positive is yet 
known. 

(b) Ulcerations. 

Ulcerations in the vagina are either of a traumatic nature (pressure 
of a ring or other foreign body, bedsores, or rather decubitus ulcers, in 
prolapse of the vagina) or ulcers of a tuhercular or syphilitic nature. 
The former correspond to those ulcers discussed further on as occurring 
on the vaginal portion of the cervix; the latter differ in no way from 
similar ulcers occurring in other parts of the body. 

( c ) Hypertrophy. 

Hypertrophy affects either the stroma or the epithelium, as in pro- 
lapse of the vagina. Here there is a decided increase of the connective 
tissue and of the epithelium, Avhich takes on an epidermis-like character ; 
or there may be an epithelial hypertrophy, as in pointed condylomata. 
At times the vagina is studded with the latter. The anatomical picture 
is the same as that given for condylomata of the vulva. 

(d) Neoplasms. 

(a) Epithelial. 

Under this heading only carcinoma is taken into consideration. It 
is primary only rarely, but frequently secondary through extension of 
a carcinoma of the cervix to the vagina. In its structure it resembles 
carcinoma of the skin and always originates from the squamous epithe- 
lium. It penetrates quickly into the surrounding tissue and changes the 
soft and dilatable vaginal canal into a rigid mass. The seat of the 



28 PATHOLOGICAL ANATOMY OF THE VAGINA. 

carcinoma is usually upon one wall, especially the posterior, or it may 
surround the entire vagina like a ring. 

(5) Neoplasms of the Connective-Tissue Group. 

These are still more rare than carcinomata. Of the benign tumors, 
fibromata and fibromyomata have been described. As to sarcomata, it 
is to be especially remarked that they may occur in childhood. Micro- 
scopically they have the well-known forms — spindle-celled, giant-celled, 
and melanotic sarcomata. 

(e) Cysts. 

Cysts of the vagina lie directly under the squamous epithelium and 
rarely attain great size. Their lining is either squamous or cylindrical 
epithelium. Some contain ciliated epithelium. Concerning the origin 
of these cysts there is, as yet, no absolute agreement. The small cysts 
may, with reason, be considered glands abnormally present in the vagina, 
or may be viewed as cysts resulting from remnants of the Wolffian duct. 
The larger, on the contrary, which reach higher up and are found along 
the uterus, may positively be considered as the result of persisting 
Wolffian or Gartner's ducts. (See Part III.) 

Finally, lymph cysts may be formed from dilated lymph channels. 
The contents of vaginal cysts consist of a clear watery fluid; it may, 
however, become cloudy as a result of desquamation of epithelium. 



III. THE NECK OF THE UTERUS (CERVIX UTERI). 

We distinguish in the uterus the body or corpus, and the neck or 
cervix. The part which extends into the vagina is called the vaginal 
portion of the cervix, or portio vaginalis. 

The cervix is perforated longitudinally by the cervical canal. This 
opens at the vaginal extremity as the external os, and above into the 
uterus as the internal os. Its walls are formed of strong muscle, which 
is covered externally by peritoneum. The external surface of the vaginal 
portion is covered by a continuation of the vaginal epithelium. Under 
it lies a small strip of connective tissue which may be viewed as the 
stroma of the vaginal portion. The connective tissue passes directly 
on into the muscular tissue, so that an anatomical line of division be- 
tween the vaginal portion and the rest of the cervix does not exist. 
Such a division, as is made by some authors, cannot be carried out in 
practice, since, for instance, in making a test excision tissues of both 
parts are always removed. We consider, therefore, in the following dis- 
cussion the neck of the uterus as a whole, consisting of the vaginal por- 
tion, cervical mucous membrane, and cervical stroma (connective tissue 
and muscle). 



THE CERVIX UTERI. 

1. NORMAL ANATOMY. 



29 



The vaginal surface of the cervix is covered by stratified squamous 
epithelium which is the continuation of the epithelium of the vagina. 
Just as the latter is a continuation of the external sldn and loses, where 
it becomes mucous membrane, the positive characteristics of the external 
skin, such as hair and glands, so there remains to the mucous membrane 
which covers this part of the uterus nothing but squamous epithelium. 
The existing papillae are here so insignificant that we can scarcely speak 








FiGUKE 4. LOKGITUDIXAL SECTION THROUGH A UtERUS. 

a, vaginal mucous membrane ; 6^ epithelium of the outer surface of the vaginal portion 
of the cervix (squamous epithelium) ; g, connective-tissue stroma; 6,, external os ; e, in- 
ternal OS ; ^, cervical mucous membrane ; g, endometrium ; U, muscle tissue of the cervix ; 
\, muscle tissue of the fundus ; i, peritoneal covering. 

of a real papilla. The underlying tissue is only loosely connected mth 
the covering epithelium. 

The papillae are small, low, and rise only slightly toward the epithe- 
lium which covers the underlying tissue in an almost straight line. 

The squamous epithelium consists of several layers which are like 
those of the external skin. Horny cells are absent ; the uppermost layer 
is formed of flattened, sometimes fusiform, elements. The projections 
are rarely seen in alcohol specimens. Under these come the cells of the 



w 



THE CERVIX UTERI. 



rete Malpighii, which consist of the well-known large squamous epithe- 
lial cells (prickle cells). It may be considered, in general, that the 
squamous epithelial cells of the vaginal portion are smaller than those 
of the external skin. The lowest layer, which forms the boundary be- 
tween the squamous epithelium and the stroma, shows low cylindrical 
cells with relatively large nuclei. This is the so-called formative layer 
(stratum germinativum), from which the thrown-off cells of the upper 
layers are replaced by new ones. 




Figure 5. — Vaginal Surface of the Cekvix Uteei. 

a-dj, squamous epitlielium ; a, layer being cast off; hj, spindle-shaped cells (stratum 
granulosum ; c, rete Malpighii ; d, stratum germinativum ; e, capillaries ; fj fibrous con- 
nective tissue with nuclei; g^ veins; h, arteries (longitudinal section) ; i, arteries (trans- 
verse section). 



The tissue under this epithelium consists, in its upper part, of con- 
nective tissue rich in cells, while the deeper layers are formed by the 
muscular tissue radiating from the corpus uteri. As a rule only the 
nuclei of the connective tissue are visible, while the cell boundaries are 
seen with difficulty. Therefore, some authors call it a connective tissue 
■"rich in nuclei." 



THE CERVIX UTERI, 



31 



Glands are normally not present in this stroma, only capillaries, 
arteries, veins, and sections of lymph, vessels. According to recent in- 
vestigations, numerous elastic fibres are present. 

The arteries are remarkable for their relatively thick walls and for 
the strong development of the intima, wherefore they impress the in- 
experienced as being glands. 

The squamous epithelium covers the external surface of the vaginal 
portion up to the external os, and only in rare cases passes on into the 
cerAdcal canal. Here it changes to a simple ciliated cylindrical epithe- 
lium. Since the cilia can no longer be seen in the sections, we will speak 
of these cells as cylindrical epithelium, just as in Fig. 6, c, no cilia are to 
be seen. 

The point of junction of these two forms of epithelium is not a 
certain one; sometimes it is situated high up in the cervical canal, at 




FiGUKE 6. 

Transition (a) of the squamous epithelium (h) of the portio vaginalis to cylindrical epi- 
thelium (cj of the cervical lining ; d, stroma. 

other times it is outside of the external os. As a rule this point of 
transition can be macroscopically recognized, for the surface covered 
with cylindrical epithelium lies rather lower than that covered with 
squamous epithelium. Besides, the color of the former is a lighter red. 
The transition may be gradual, the squamous epithelium becoming grad- 
ually thinner, or it may go over into cylindrical epithelium suddenly. 
By some authors a transition epithelium has been described. 

The cylindrical epithelium covers the cervical stroma in an uneven 
line, and forms depressions, the well-known cervical glands. These are 
designed to secrete a glairy mucus which fills the cervical canal as 
a plug. 

The glands do not extend very far into the underlying tissue, but 
their bottle- or balloon-shaped forms occupy only the upper part. The 
higher we pass in the cervical canal the more uneven is the surface of 
the mucous lining. The reason for this is that the stroma forms longi- 
tudinal folds toward the lumen of the canal, in this way narrowing it 
considerably. These folds begin at the internal os and extend toward 



32 



THE CERVIX UTERI. 



the external, forming the arho^^ vitce uterinus or the plicce palmatcB. In 
this way the surface is considerably increased in extent, and in trans- 
verse sections it may be seen that the tissue lifts itself in folds, with a 
deep depression between every two folds. Here the gland openings lie 
quite hidden, while upon the summit of the folds, as a rule, no glandular 
depressions are found. The lowest portion of the cervical canal is often 
free from glands, yet it cannot be considered pathological if they are 
present at the very beginning of the cylindrical epithelium. 

The lumina of the glands have no regular round form, but are 
compressed by folds which project from the stroma toward the epi- 
thelium. In this way the cells of the opposing walls often approach 
each other so closely that no lumen remains. 

The epithelial cells have a long, transparent protoplasmic body 




Figure 7. — Cervical Mucous Membrane. 

a, gland openings (cut obliquely) ; 6^ cylindrical epithelium (ciliated) ; c^ connective- 
tissue stroma rich in cells ; d, capillaries filled with blood ; e, oblique section through cer- 
vical glands. 



narrowing toward the base. The nucleus, which is small in proportion, is 
situated at the base. The cilia can be found, as a rule, only in the fresh 
specimen, examined in physiological salt solution immediately after re- 
moval. Through addition of caustic potash ciliary motion may be again 
excited. 

The stroma of the cervix consists of connective tissue rich in cells 
only in the layers directly under the epithelium. The main constituent 
of its wall is formed by muscle fibres into which the fundi of the glands 
project. Next to the muscular tissue is the paracervical tissue, loose 
connective and fat tissue. 

So much for the normal anatomy of these parts. There remains to 
be considered only the topographic condition of the glands situated near 
the boundary of the squamous epithelium. These do not run into the 



THE CERVIX UTERI. 33 

tissue at right angles to the surface, but often make a bend under the 
surface and lie parallel to the squamous epithelium in a longitudinal 
direction. If in such a case a vertical section be made through the sur- 
face covered with squamous epithelium, there will be found under it 
one or more sections of glands, which, however, are in no way patho- 
logical, for this apparent abnormal condition is caused by the manner 
in which the section is made and is not due to an increase in the glands. 
To determine with certainty to what part such a gland belongs, and 
whether it is a normal gland formation or a newly formed gland, the 
entire specimen must be cut in a series of sections, to follow the gland 
up to its excretory duct. Such a procedure is necessary only in ex- 
ceptional cases. It serves, however, to remind us that in examining our 
specimens we are often liable to such illusions, ignorance of which may 
easily lead to serious error. This may be the more easily understood 
when we consider that just in the cervix two different forms of epithe- 
lium meet, each of which is liable to decided changes of form upon the 
slightest irritation. First one and then the other form of epithelium 
gets the upper hand; an extremely vigorous growth, as a reaction to 
every irritation, is a quality common to both. In addition there may be 
a varying increase in the glands. It is therefore especially advantageous 
to the beginner if he learns of the existence of such constantly occurring 
''illusion pictures" before he begins to consider pathological processes. 

MICROSCOPICAL ILLUSIONS. 

(a) In Sections through the Squamous Epithelium. 

We are accustomed to study the squamous epithelial covering of a 
surface in transverse section. Drawings of the same are usually ar- 
ranged so that the different layers may be distinctly distinguished. If 
the section is not quite perpendicular to the surface, but more nearly 
parallel to it, the section makes a strange impression, for we see no longer 
the various layers, but only some of them ; and these not in profile, but 
from the surface. The epithelial extensions which occasionally run 
deeper into the underlying tissue are no longer cut longitudinally but 
transversely, and may be mistaken for masses of squamous epithelium, 
such as are sometimes found in carcinomata. The entire epithelial sur- 
face appears thicker, and this condition may be easily illustrated in the 
section through a pointed condyloma (Fig. 8). 

In this affection we find a hyperplasia of the epithelium which grows 
in all directions, so that in a section the epithelial surface is cut some- 
times vertically, sometimes obliquely, and sometimes parallel to the 
surface. 

In the case of the vaginal portion also such irregularities of the 
epithelium occur, when in alcohol some of the parts of the specimen 



34 



MICROSCOPICAL ILLUSIONS. 



shrink more than others, so that elevations and depressions are formed. 
In a somewhat oblique section islands of squamous epithelium may then 
be found in the stroma and easily lead to error; at least I have often 
observed that the inexperienced examiner considers such fields to be 
carcinomatous. 

In judging a section it must be held "in mind that the vaginal sur- 
face of the uterus which is covered with squamous epithelium runs an 
arched course and not in a straight line. If then the section is made 
through the curving part a portion of the epithelium is so cut that the 







¥HWM 



^.Z^' 






'"•MM? 






Figure 8. — Suction through a Pointed Condyloma. 

a, squamous epithelium (oblique) ; Ta, oblique section of a papilla; o, islands of squa- 
mous epithelium, seen in various planes, showing at 6, an enclosed bit of the horny layer 
which resembles a cancer pearl ; e, stroma infiltrated with small cells. 



section is almost vertical, while the curving portion is, on the contrary, 
cut at a tangent, whereby the epithelium appears suddenly thicker and 
seems to penetrate into the underlying tissue. 

• For that reason, to avoid error one must carry in mind the appear- 
ance of sections cut in various directions. The beginner is therefore ad- 
vised to purposely cut the specimen to be diagnosed in various planes. 
Even almost normal specimens then offer difficulties for the beginner 
if the line of cutting be unfavorably chosen. If at the same time 
pathological changes (inflammation, hyperplasia) be present, even a 
practised pathologist may have difficulty in making a correct diagnosis. 



MICROSCOPICAL ILLUSIONS. 



35 



The chief criterion in deciding whether we are dealing with an ob- 
lique section or a pathological condition is the regular disposition of the 
epithelial cells to each other and the condition of the interstitial tissue ; 
for if a malignant neoplasm penetrates into another tissue the latter 
does not remain unaffected, but reacts with a small-celled infiltration. 
There are then numerous lymphoid cells in the interstitial tissue, which 
take up the struggle against the neoplasm. In this way it is clear 
that a decision may be very difficult if the connective tissue for some 
other reason (inflammation) is already infiltrated with round cells. 
Then the regular form of the epithelial cells decides. A carcinomatous 
or sarcomatous neoplasm — in doubtful cases one of these is generally 
in question — does not contain regularly arranged cells of the same form, 
but distinguishes itself through a multiplicity of cell forms. In dis- 
cussing carcinomata this condition will be considered more fully. 

(b) In Sections through Glands Lined with Cylindrical Epithe- 
lium. 

As in the case of squamous epithelium, drawings of glands are usually 
so made that the cylindrical cells are seen from the side. If the gland 
be cut longitudinally, a tube lined with cylindrical cells is seen; if, on 




Figure 9. — d, Longitudinal Section through 

A Gland Lined with Cylindrical 

Epithelium. 




CP 




7N 




Figure 10. — Transverse Section through 
A Cylindrical Cell (a, h). 

a, beyond the boundary of tbe nucleus ; 
6, nucleus also included. 



Figure 11. — Oblique Section through a 
Gland. 
a, transversely cut cylindrical cells of a 
deeper layer ; 6^ gland lumen ; c, transverse 
or obliquely cut cylindrical cells resembling 
an epithelial proliferation. 



the contrary, it be cut transversely, a circle is formed lined with cyl- 
indrical cells in profile. The cells then appear as longitudinal long cells 
with a large or small nucleus at the base. 

The course of the gland is only in rare cases so simple and straight 



36 



MICROSCOPICAL ILLUSIONS. 



that a section in all parts divulges a simple layer of epithelium, and this 
always in the same plane. Since, in addition, the uterine glands have a 
winding course, it is rare to see other than oblique or flat sections. In 
keeping with this result the cylindrical epithelia are not always seen 
in profile, but usually obliquely or from the surface; they then have 
no longer a cubical form, but appear broad, like squamous epithelium. 
Further, in a section a cell with or without its nucleus may be seen, ac- 
cording as the section includes the nucleus or not. 




Figure 12. — Section theough the Fundus of a Gland. 

a, gland lumen lined with cylindrical epithelium ; 6, horizontal section through the cyl- 
indrical epithelium ; c, interglandular tissue ; d, section through the gland fundus ; e, space 
rei?ulting from the greater shrinKing of the epithelia in the alcohol. 



A section not entirely vertical cuts the cells of the glandular wall in 
such a manner that on one side the cells are seen in profile, while on 
the other side oblique sections of the epithelium are seen. At the same 
time not only one but several layers of cells are seen in such an oblique 
section. This makes it appear as if the epithelium were in a state of 
growth, and may lead to erroneous diagnosis (Fig. 11). 

While in oblique sections a lumen is always present, it disappears in 
a section through the fundus of a gland (Fig. 12). We see then only 



MICROSCOPICAL ILLUSIONS. 37 

the transversely cut cylindrical cells as a mass of epithelium lying in 
tissue, the entire picture resembling a carcinomatous alveolus. At any 
rate, I have frequently observed that beginners, and even practise^ 
microscopists, confuse these two conditions. 

The chief differences consist in the regular arrangement and in the 
similarity of the cells. By high magnification it may be distinctly seen 
that the transverse sections of the epithelial cells have polyhedral forms 
like the cells of a honeycomb. If the interstitial tissue is not otherwise 
altered, a decision as to the existing condition is not difficult, and may, 
with practice, be made with certainty. If, on the other hand, complicat- 
ing inflammatory changes are present — and this is especially the case in 
the endometrium — not only is the interstitial tissue infiltrated with small 
cells, but in most cases there has been great irritation of the epitheliuro 
of the glands, which is then incited to growth and really lines the wall 
in many layers. 

Between the epithelia round cells make their way, and if the section 
shows these altered conditions obliquely or from the surface it is evident 
that under such circumstances a correct diagnosis of the true nature 
is difficult, for through the strong small-celled infiltration the bound- 
aries of the glands appear obliterated, so that it seems as if they no 
longer existed — a condition which is one of the chief characteristics in 
carcinoma. 

In such a case all diagnostic means must be called into play to 
insure a correct diagnosis. This is possible if the course of the glands 
be followed in a series of sections. Further, attention must be paid to 
the division of the nuclei. The finer diagnostic points will be discussed in 
the chapter on the diagnosis of malignant neoplasms. It is naturally 
impossible to discuss all the possible errors; I can only call attention 
to this point and mention that illusions are to be avoided in judging 
microscopic pictures. At any rate, if this fact be always borne in mind, 
practice in diagnosing the pathological changes in these organs will 
serve to distinguish them from these so-called illusions. 

2. PATHOLOGICAL ANATOMY. 

The outer surface of the cervix, when seen with the aid of the 
speculum, appears covered with a moist, shining, bluish-red mucous 
membrane which possesses a smooth surface, and is, as we have seen, 
the continuation of the vaginal mucous membrane. Such an appearance 
corresponds to the microscopical condition observed in the previous 
chapter, and is never a justification for a test excision. 

When, on the other hand, the mucous membrane does not cover the 
entire surface of the vaginal portion, but suddenly ceases, giving place 
to smaller or larger, very red, uneven, and lightly bleeding spots, we 
are dealing with a pathological state. This ulcerating surface lies some- 



38 CERVIX EROSIONS. 

times below the level of the mucous membrane, sometimes it rises above 
the surface in the form of excrescences. Usually this affection is found 
near the external os and extends from here in varying extent toward 
the vagina, which in extreme cases may likewise be affected. It is rarely 
that the external os is surrounded by normal mucous membrane while 
the affection is found further away. 

In general, we may say that the macroscopical appearance of these 
various ulcerating processes is no complex one. This is probably the 
reason why all these changes of the vaginal portion have been given the 
collective name "erosion." This name characterizes the external ap- 
pearance in this affection, but does not define its nature, for an erosion 
means, in general, loss of the epithelium of a mucous membrane. Since 
it is impossible, with the naked eye, to decide whether a surface is 
covered with epithelium or has lost it, especially when this surface is 
inflamed, it is evident that the term "erosion" is often used when in an 
anatomical sense no such condition is present. Attention has been called 
to the insufficiency of this clinical title, but no other proposals have met 
with general approbation. 

The differences in the morbid processes which possess a like macro- 
scopical appearance make it impossible to select a uniform name which 
corresponds at the same time to the etiological and the microscopical 
condition, for very different causes may bring about a like macroscopical 
appearance in one or other of the pathological stages. It is to be re- 
gretted that the expression "erosion" has been chosen, for it tends 
to cause erroneous impressions; at the same time it is difficult to giv€^ 
up this nomenclature. We will, therefore, for the present, use this ex- 
pression for the macroscopical appearance of the conditions to be de- 
scribed. In order that no confusion may result, it must be understood 
that this term expresses only the external appearance of the affected 
area, without making any statement as to the anatomical changes ex- 
isting. How unsatisfactory this title is, or rather how false it is, will 
be seen in observing the simple inflammations of the vaginal portion; 
for here the surface appears macroscopically very red, like an inflamed 
tonsil, yet the squamous epithelium is entirely present. If it is desired to 
unite all these conditions of the vaginal portion under one name, it is 
only possible by choosing a title which expresses nothing more than the 
macroscopical appearance. 

In the following discussion the individual affections of the vaginal 
portion will be given names corresponding to the microscopical con- 
ditions w^hich they present. 



INFLAMMATIONS OF THE PORTIO. 39 

(A) INFLAMMATIONS. 
(a) Simple Inflammations op the Portio Vaginalis. 

In simple inflammation of the vaginal portion tlie connective tissue 
shows a decided small-celled infiltration. The vessels, especially the 
capillaries, are dilated, and turgid with blood. Under the surface 
numerous new capillaries have been formed, and about these the group- 
ing of round cells is the greatest. Usually the inflammatory process is 
the more energetic the nearer we approach the surface. Toward the 
muscularis the small-celled infiltration is less, and ceases entirely in the 
muscular interstices. 

Close under the epithelium the connective tissue, rich in nuclei, is 
often changed to granulation tissue. In the individual cells the trans- 
ition from small round cells to spindle and epithelioid cells may be 
observed. The surface squamous epithelium is also affected. The epithe- 
lium is in many places infiltrated with leucocytes and becomes hyper- 
trophic through the increased blood supply. While in a normal con- 
dition it covers the stroma smoothly, in inflammatory states numerous 
papillae are formed, which press up to the surface and are supplied with 
turgid capillaries. This explains the red color of such a cervix, although 
the epithelium may not be absent. 

A simple inflammation of the vaginal portion is relatively rare as a 
primary condition. It may be produced by a strong congestion of the 
genitalia through venereal excesses or mechanically through irritation 
of a pessary worn for a long period, etc. Gonorrhea may also cause such 
an inflammation. In the glands and in the interstitial tissue gonococci 
may then be found. 

At times such a condition means nothing more than that an ulcer- 
ating surface has gone on to healing. This healing takes place by pro- 
gression of the epithelium from the edge of the ulceration until it covers 
the entire ulcerated surface. At the same time the small-celled infiltra- 
tion may remain, so that the anatomical picture resembles that of a new 
inflammation. The difference between these two processes can be de- 
termined by close examination. If we are dealing with a healing ulcer, 
as a rule decidedly fewer cell layers are found from which the squamous 
epithelium is formed. Besides, degenerating elements are found in the 
inflamed tissue in addition to the products of a fresh inflammation. The 
former are evidence of the fact that we are dealing with a process which 
has existed for some time. Inflammations of this form, but of a sec- 
ondary nature, are more frequent, and then they are of decided im- 
portance in diagnosing certain affections. 

We will later consider in detail the fact that just in the neighbor- 
hood of carcinomata very often decided small-celled infiltrations occur 
as reactions of the tissue against the penetrating neoplasm. It is there- 
fore necessary to consider the cause of such a strong small- celled in- 



40 ULCERS OF THE PORTIO. 

filtration in the vaginal portion and to remember that a primary in- 
flammation of this part is rare. It is therefore advisable to hold a pa- 
tient under observation, even though the first examination has disclosed 
nothing further, and after a certain period another test excision should 
be made, especially if the clinical symptoms show no improvement. 

There is yet another point to be observed. If, because of a very 
marked small-celled infiltration, a suspicion arise that a neoplasm exists, 
the sections should be made very thin, for then we are often concerned 
with a carcinoma which has existed only a short time or one which 
shows an unusually rapid growth. Such carcinomata do not form large 
typical alveoli which may be recognized at the first glance, but oc- 
casionally three or four cells form a carcinomatous alveolus. If the 
small-celled infiltration is very decided and the section very thick, then 
the carcinoma cells disappear under the small-celled infiltration and 
may in this way be overlooked. On the other hand, if the sections are 
thin the epithelioid carcinoma cells are easily distinguished from the 
small round cells. In the course of an inflammation brought about by 
mechanical causes a complete removal of the epithelium of the vaginal 
portion may result, with consequent destruction of the upper layers of 
tissue and the formation of an actual ulcer. 

(b) Ulcers of the Portio Vaginalis. 

A real ulcer occurs relatively seldom on the vaginal portion. The 
anatomical character of such an ulcer is very similar to the conditions 
which we have observed under inflammation, with the difference, natur- 
ally, that the surface is no longer covered with epithelium. In the 
uppermost layers the small-celled infiltration is especially strong. Fre- 
quently, in addition to turgid capillaries, extravasations of blood are 
observed in the tissue. Finally, in accordance with the character of an 
ulcer, the products of degeneration are much more numerous than in 
a simply inflamed tissue. The diagnosis of a simple ulcer offers no diffi- 
culties if one only remembers that the surface of a carcinoma also fre- 
quently shows ulcerating degeneration, and that underneath an ulcer a 
carcinoma may exist. 

The causes for the existence of a real ulcer on the vaginal portion, 
naming the rarer cases first, are the same as for ulcers in other parts 
of the body, namely, syphilis and till:) erculo sis. Concerning these two 
processes on the vaginal portion very few observations have as yet been 
made. Such reports concern only occasional cases. This is especially 
striking in the case of syphilis, since this affection causes a productive 
inflammation, and thereby the epithelial growths on the vaginal portion 
due to syphilis may greatly resemble the changes caused by carcinoma. 
This error is possible, since two different forms of epithelium unite on 
the vaginal portion, both of which have a great tendency to proliferation 
after relatively small irritation. In my opinion, examination in this 



ULCERS OF THE PORTIO. 



41 



direction possesses a great anatomical interest and is of great importance 
for the clinical diagnosis and the differential diagnosis of the "early- 
stage of carcinoma." 

Even though, in considering an ulcer of the vaginal portion, these 
conditions must always be kept in mind, purely mechanical causes are 
the more frequent cause of their development. In prolapse, as well as 
from long-existing pressure of a pessary, such an ulcer may be formed. 
Since in prolapse decubitus ulcerations are not infrequently observed, 
a doubt may arise in such a case as to w^hether a carcinomatous ulcer is 
present. For that reason we will study such an ulcer more closely. 

As a result of prolapse the cervix comes in contact with the outer 
air. This causes so decided an irritation that the squamous epithelium 




FiGuuE 13. — Decubitus Ulcer of the Vaginal Portion in Total Prolapse of the 
Uterus (f. end of the epithelium; to the left hegins the ulcerating surface). 

a, ulcerating surface : 6, small-celled infiltration of the stroma ; c^ capillaries ; d, much- 
thickened squamous epitheliiim whose upper layers are being cast off ; e, transverse and 
oblique sections through papillae. 



is increased to three or four times its normal thickness. This thicken- 
ing appears, in a measure, to be an aid of nature in protecting the uterus 
from external injuries. Nevertheless, in many cases the epithelium is 
gradually thrown off through rubbing between the thighs, and actual 
ulcers are formed. If a vertical section through the surface of such an 
ulcer be made, we find, if an area of transition from healthy to diseased 
tissue has been selected, a small-celled infiltration under the epithelium 
in the neighborhood of the ulcer. This infiltration reaches its height 
in the areas entirely bare of epithelium, and at times extends far down 
into the tissues. 

The deeper the ulcer penetrates, the more irregular is the surface 
and the more natural is a diagnosis, judging from its macroscopical ap- 



42 ECTROPION. 

pearance, of malignant neoplasm; for in these ulcers a symptom often 
of value in making the clinical diagnosis of carcinoma is present, 
namely, the easy bleeding on touch, either instrumental or through 
coitus. Since, however, the uppermost layers of such simple ulcerating 
surfaces, deprived of epithelium, are filled with numerous turgid blood 
vessels possessing only thin walls, the free bleeding when touched is 
easily understood. It may also be mentioned that these ulcers are only 
in the rarest cases the starting point of a carcinoma. On the contrary, 
as soon as the injuring cause is removed they readily heal. 

(c) Ectropion and Inflammation of the Cervical Mucous Membrane. 

As was seen in reviewing the normal condition, the stratified squa- 
mous epithelium of the vaginal portion borders on the cylindrical epi- 
thelium of the cervical lining with its glandular depressions. In the 
virginal uterus the boundary between these two forms of epithelium lies 
sometimes higher, sometimes lower in the cervical canal. At any rate, 
the outer surface of the uterus is normally never covered with cylin- 
drical epithelium. This condition is different as soon as one or more 
births have occurred, for after these the external os is generally torn so 
that it gapes more or less according to the depth of the tear. In this 
way the previously invisible mucous lining of the cervix appears on the 
outer surface, while the part covered with squamous epithelium is forced 
back toward the fornix. In this manner cylindrical epithelium occupies 
the position previously taken by the squamous cells, and the so-called 
*' ectropion" results. This appears (in a multipara a relatively normal 
condition) as an extremely red area in place of the normal blue and 
shining vaginal portion, and the numerous glands Avith their uneven sur- 
face give this condition an ulcerating appearance. This impression is still 
stronger if external irritation or congestion or a pregnancy makes the 
blood supply greater and gives the surface a dark-red appearance. This 
picture is still more characteristic, and its appearance is more like that of 
an ulcer, if in addition inflammation be present. The complicating in- 
crease of blood supply, and the infiltration of the tissue with lymphoid 
cells, may cause a very decided swelling of the cervical mucous mem- 
brane. This may be so decided that the cervical lining, welling out of 
the external os, rests upon the outer surface of the cervix like a fungus. 

The microscopical changes found in inflammation of the cervical 
mucous membrane hold good for the everted mucous membrane as well 
as for the non-everted. 

The stroma is inflltrated with small cells ; the vessels, especially capil- 
laries, are filled with blood. The glands, as a rule, are not changed in the 
early stages, but in certain areas leucocytes may be found between the 
epithelial cells. As may be readily understood, this stage is rarely ob- 
served microscopically, examination being usually made when the pro- 



ECTROPION. 43^ 

cess is more advanced and when great changes have resulted through 
chronic inflammation. 

Then, in the first place, the glandular structures demand our atten- 
tion. As a result of the continued excessive plethora, perhaps through 
the irritation which causes the inflammation, hyperplasia of the glandu- 
lar epithelium results. This is evidenced either by a growth of the 
epithelial cells inside the glands, or in an increase in size and number of 
all the glands. 

If the latter be the case, we see the glands forming the chief element 
of the tissue, while the interstitial tissue is more and more displaced by 
them. The glands, increased in number (hyperplasia), are situated 
close together, but preserve their epithelium and their glandular form 
without change. Besides, this growth caused by inflammatory processes 
remains confined to the superficial layers of the mucous membrane. 

In case of enlargement (hypertrophy) of the glands they increase 
considerably in length and size. In some cases, although they are nor- 
mally only depressions of the cervical epithelium, they may pass through 
the entire thickness of the vaginal portion up to the squamous epithelium, 
where they sometimes lift the latter off entirely. Through a coexisting 
proliferation of the connective tissue the glands possess no even calibre, 
but are narrowed by projecting folds. These may lie so close together 
that a canal is scarcely present. The cells of the opposing sides are in 
contact, and may even unite. Since the irritating cause increases the se- 
cretion of the epithelial cells, and since the narrowing of the gland 
lumen permits no sufficient outflow, an excessive dilatation of the glands 
may result. These may in the course of time be cut off from their ducts 
and form cysts. 

The clinical symptom of such a condition which may lead to test 
excision is frequent, irregular bleeding vnth purulent discharge. If the 
microscopical picture corresponds to the above description, no doubt 
should exist that we are dealing with a benign formation. 

It is different when an inflammation causes a hyperplasia of the 
glandular epithelium alone, for then the glands are no longer lined mth 
a single layer of epithelial cells, but the latter are found in three or four 
layers. It may happen that the cells lose their cylindrical shape 
through pressure and become flat. If then an oblique section should be 
examined the sections through these flattened cylindrical cells look like 
squamous epithelium, and the impression is easily made that the gland 
lumen, partly filled with epithelia, is a carcinoma in a very early stage. 
Although we readily grant that such microscopic pictures require great 
care in judging a pathological process, we state that it is adsolutely in- 
correct to make from this condition alone the diagnosis of a ^ ^beginning 
carcinoma/' for from the above description it may be seen that such 
epithelial groAvth within a gland may easily be the result of inflamma- 
tory changes. 

Nevertheless it is to be recommended that such cases be carefully 



44 



ECTROPION. 



watched and that new test excisions be made at regular intervals, pro- 
viding, naturally, that the clinical symptoms, such as bleedings and dis- 
charge, do not disappear after continued treatment. 

With what little right a beginning carcinoma would be diagnosed 
from such conditions, the following case observed by me may serve as an 
example. Fig. 14 gives an illustration of the same. 




Figure 14. — Test Excision from the Vaginal Portion after Much Cauterization. 

Benign growth of epithelium in a gland. Epidermization of the surface. On upper 
side, to the right, a gland enters into the tissue and is cut obliquely. Below, to the right, 
are retained cylindrical cells in the gland otherwise filled with squamous epithelium. 



The patient came to my clinic for uncontrollable bleeding from which 
she had suffered for six weeks, during which time she had been under 
medical treatment and observation. The "erosion" was cauterized by 
her physician with crude pyroligneous acid. As the bleedings did not 
cease, he performed a curettage, and at the same time made a test ex- 
cision, since the vaginal portion looked suspiciously like carcinoma. His 



EROSIONS 15 

examination of the excised piece led to no diagnosis, for it was too small 
and Avas spoiled in preparation. In spite of the curettage the bleedings 
continued, and the vaginal portion was treated exclusively with chloride 
of zinc, at first in weak and then in stronger solutions daily up to fifty 
per cent. The result was that the bleedings became stronger and actu- 
ally intense when she came into my hands. Examination showed the 
vaginal portion to be strongly granulated and ulcerated; it bled on the 
slightest touch, so that macroscopically it had the appearance of a car- 
cinoma. After the above history, however, it seemed advisable to at- 
tribute its appearance to the above mentioned cauterization. Still, I 
considered it advisable to make a test excision, with the microscopical 
result shown in Fig. 14. 

Without doubt this condition could justly be called a "beginning 
carcinoma." Since the irritation of the long-continued treatment and 
the repeated surgical steps appeared to me sufficient to explain this de- 
cided growth of epithelium, I treated the patient with a simple gauze 
tamponade and absolute rest. After a few days the bleeding ceased and 
the patient recovered quickly from the loss of blood. Menstruation re- 
turned regularly upon the use of extract of hydrastis. On seeing the 
patient, after a lapse of six months, she was in perfect health, men- 
struation was regular, and the vaginal portion was of normal appear- 
ance. May this case serve as an example of a large category ! At any 
rate, it furnishes proof that a diagnosis of carcinoma should not be too 
hastily made. It is necessary to remem'ber that in every inflammation 
hyperplasia of the epithelia may occur, and the pathological process must 
be judged accordingly. 

(d) "Erosions'^ (Erosio Epithelialis Superficialis). 

After ha^dng discussed real ulcers of the vaginal portion, the follow- 
ing division deals ^^dth those conditions which are frequently found, and 
which have occasioned the calling of all very red-looking changes of the 
vaginal portion "erosions.'^ 

This condition is characterized by the fact that the vaginal surface 
of the cervix, which normally is covered with squamous epithelium, 
shows the presence of cylindrical epithelium to a greater or lesser extent. 
This causes a great resemblance to ectropion and a distinction micro- 
scopically between the two is often impossible. This is possible macro- 
scopically only when an erosion occurs on the cervix of a nullipara or a 
virgin. Then the bluish-red, normal epithelial covering is substituted 
by a deep-red surface which, as a rule, surrounds the external os. At 
times, yet comparatively rarely, such areas occur far from the external 
OS. These are sharply outlined from the surrounding mucous mem- 
brane ; sometimes they lie at a deeper level. The change in the vaginal 
portion varies according to the extent of the affection. In advanced 
cases the macroscopical appearance shows such a torn, uneven, granular 



46 



EROSIONS. 



character that carcinoma is immediately considered. If, in addition, 
such a surface bleeds easily on touch, then without doubt a test excision 
is justified. In microscopical specimens it is seen that, in place of squa- 
mous epithelium, cylindrical epithelium is present. There is, therefore, 
no complete loss of the surface epithelium, and an "erosion," in the 
pathological-anatomical sense of the word, is not present. 




Figure 15. — A So-callbd "Erosion" of the Vaginal Portion (section showing transi- 
tion from cylindrical to squamous epithelium). 
a, squamous epithelium, interrupted at b through pressure of the vulsellum ; c, cylin- 
drical epithelium as covering of the surface usually covered with squamous epithelium ; 
d, glandular depressions extending far under the squamous epithelium ; e, stroma in- 
filtrated with small cells. • 



The stroma shows in most cases slight changes. In spots there is a 
small-celled infiltration of slight intensity. The surface is covered with 
a simple cylindrical epithelium ; I have never observed cilia. This epi- 
thelium covers the stroma in parts evenly, in parts it forms slight de- 
pressions into the underlying tissue. As a rule, glandular-like structures 
are found in the stroma, i. e., transverse and longitudinal sections of 
tubes lined with simple cylindrical epithelium, which in general is lower 



EROSIONS OF THE CERVIX. 4:7 

than that of the cervical glands and shows no cilia. This stage of the 
affection has been called ^^ simple erosion" so long as only few glandular 
structures are present in the stroma. If, on the other hand, the cylin- 
drical epithelium passes deep into the stroma, and then rises again to 
its original level, papillary structures are formed which in the gyneco- 
logical-anatomical literature are called '^papillary erosions." If the 
surface is smoother, and if at the same time there are more epithelial 
depressions, the condition is called ^'follicular erosion." These expres- 
sions only confuse the beginner, since ''papillary" and ''follicular" are 
already confined to other conditions; especially is this the case with the 
word "papillary." It is always difficult to make the beginner, who has 
pursued anatomical studies, understand that in this branch of patho- 
logical anatomy we are not dealing here with real papillge. In addition, 
among the above-mentioned three subdivisions of "erosion" no one 
form is exclusively present, but the various divisions run into each other. 
It would be best, in my opinion, to accept for general use the title 
adopted by me. '^Superficial epithelial erosion" signifies a condition in 
which cylindrical epithelium is present on the surface of the vaginal por- 
tion normally covered ivith squamous epithelium. This continues, some- 
times deeper, sometimes not so deep, into the stroma, in which at times 
feiv, at times very nunierous, gland-like structures may he present 
(Fig. 15). 

The stroma shoivs small-celled infiltration in the early stages of this 
condition. After a length of time the changes in the stroma may dis- 
appear without leaving any traces, and there remains then only the 
epithelial change. The characteristic of this so-called "erosion" is that 
in a stroma which, in the normal condition, is free from glands,^ glands 
result through an unknown irritation with an isochronous substitution 
of the covering squamous by cylindrical epithelium. This change is 
clearly expressed by Orth,^ who says : "The most important and interest- 
ing point is the presence of glands similar to those occurring in the nor- 
mal lining of the cervix, so that we might say that, in place of the vaginal 
mucous membrane of the vaginal portion, cervical mucous membrane is 
present, showing, however, productive inflammatory changes. ' ' 

When erosions are present for a long time — they are generally chronic 
affections — there may occur in the stroma and in the epithelium all 
those changes which we have learned in the previous chapter on in- 
flammation of the cervical lining, therefore those conditions may be 
added here. 

I should like to discuss briefly the origin of these erosions. It must be 
mentioned that all these explanations are only hypotheses. In the first 
place, it must be granted that an irritation may cause the cervical epi- 
thelium to proliferate; that this growth of epithelium displaces the 
squamous epithelium and leads to increase, i. e., a new formation of 

iComp. Normal Anatomy. 

2Text Book of Special Pathology, p. 438. 



48 EROSIONS OF THE CERVIX. 

glands. In most cases, in fact, a cervical catarrh is present. It may be 
supposed that this continuous discharge of pathological secretion macer- 
ates the squamous epithelium, which is finally thrown off and replaced by 
the cervical epithelium engaged in proliferation. This locally displaced 
epithelium forms here, as it does in the cervix, glandular depressions. 
The presence of glands or gland-like formations has therefore no special 
meaning, but is, in a certain way, physiological. 

It may be mentioned that in nearly all organs whose surface is cov- 
ered with ciliated or simple cylindrical epithelium, glandular forma- 
tions are found. This explanation is not true in a series of cases, for it 
can be observed that catarrhs with irritating purulent secretion exist 
without the least affection of the covering' of the vaginal portion of the 
cervix, and vice versa. 

Here Fischel's interesting observation concerning "congenital histo- 
logical ectropion" furnishes an explanation of the substitution of one 
form of epithelium by the other. He believes, namely, that in the newly 
born the outer surface of the vaginal portion not infrequently has a 
cervical structure. Either in the future this "infantile habitus" per- 
sists, or in the process of development the squamous epithelium makes its 
way over the surface without the disappearance of all the cylindrical 
elements. One may then imagine that an irritation is sufficient to stimu- 
late the latter to growth and to the formation of an erosion. At the 
same time, Fischel's theory furnishes an explanation of those cases 
in which the ' ' erosion ' ' is not closely connected with the cervical mu- 
cous membrane, but forms isolated islands surrounded by squamous 
epithelium and covered with cylindrical. 

According to another theory^ the cylindrical surface epithelium, as 
well as its depressions into the stroma, originates from the stratum ger- 
minativum of the rete Malpighii. The upper layers of the squamous 
epithelium are then thrown off during this affection, while the formative 
layer remains as an independent covering of cylindrical epithelium. In 
some cases this may be true ; yet it is a theory rather more far-fetched 
than the other, for why should this layer of the stratum Malpighii, which 
usually forms only squamous epithelium, suddenly be employed in form- 
ing cylindrical epithelium? I have discussed these erosions fully, be- 
cause they play a decided role since we have learned to make test exci- 
sions of the cervix for microscopical examination. In particular it may 
be mentioned that malignant neoplasms are supposed to originate from 
them. 

According to Orth there exists a carcinomatous erosion. This asser- 
tion, first made by Kuge and Veit, is in my opinion not proven, but: is 
likely to lead the beginner to make a diagnosis of early glandular car- 
cinoma when in reality only a benign epithelial hyperplasia is present. 
I refer the reader to the discussion concerning such hyperplasia under 

iRuge and Veit. 



HYPERTROPHY OF THE CERVIX. 49 

inflammation of the cervical mucons membrane. By this I do not deny 
that carcinoma and erosion may be coexistent. My continued examina- 
tions have taught me that just in the areas which macroscopically look 
suspicious, and in which the so-called "erosion" glands were present, 
as a general rule no carcinoma is found. If the latter is present, then, 
on the contrary, the surface is really ulcerated, and an enormous small- 
celled infiltration of the stroma is present without gland formations, and 
we have a typical carcinoma originating from the squamous epithelium. 

(B) NEOPLASMS. 

In contrast to the changes previously described, in which there is 
more or less loss of substance, we are to concern ourselves in the follow- 
ing paragraph with those conditions w^hich lead to partial or total growth 
of the individual elements of the cervix. These neoplasms are clinically 
either henign (hypertrophy, hyperplasia) or malignant (carcinoma, ma- 
lignant adenoma, sarcoma). 

The advanced cases of the first kind are usually so well characterized 
that with clinical experience a correct diagnosis may usually be made 
without previous microscopical examination. As a rule, we have here 
circumscribed growths which must be removed in toto. It is different 
when the cases are viewed in their early stages. Here we operate, as a 
rule, without previous test excision (except when carcinoma is suspected, 
when I advise a diagnostic test excision) ; but we must never omit a 
subsequent microscopical examination of the extirpated tumor, for even 
in inoffensive-looking polyps destructive processes may occur, which 
after diagnosis compel the performance of a major operation instead of 
the simple removal of the polyp. Since, on the other hand, even under 
benign neoplasms microscopical pictures are found which the beginner 
may view as carcinoma, I consider it necessary to describe these changes 
before passing on to malignant tumors. 

1. Hypertrophy of the Outer Surface of the Vaginal Portion. 

The benign hypertrophies of the vaginal portion involve either the 
epithelium or the muscular structure, or both. They may lead to diffuse 
growth of these parts, and are then called hypertrophies of the cervical 
lips (elongatio colli) . If, on the other hand, only individual parts of the 
matrix go on to excessive growth, there result polyps of the outer cer- 
vical lips. 

(a) Hypertrophy of the Epithelium. 

This is most frequently observed in 

(«) Prolapse. 

A peculiar change in that part of the uterus projecting from the 
vagina is caused by friction be+ween the thighs, and by irritation through 



50 



HYPERTROPHY OF THE CERVIX. 



the air from which it was previously protected. This concerns exclusively 
the epithelial covering, and it is observed that the original moist, velvet- 
like polish and the red color have disappeared and given way to a dry 
tissue and a grayish color. This change is the result of an enormous 
hypertrophy of the epithelium. In place of four or five layers, twenty to 
thirty appear, the uppermost of which have the character of the horny 
layer of the external skin and are constantly in a state of desquama- 
tion and regeneration. The papillge, originally scarcely to be observed, 
enlarge greatly and form wide elevations, sometimes slight prolonga- 
tions of the stroma, which penetrate the entire layer of pavement epi- 
thelium. The mucous membrane is, in fact, made into epidermis. This 
condition resembles exactly the external skin, with the absence, of course, 
of the special elements of the same (see Fig. 13). 

In most cases the line of division between this thickened epithelium 
and the underlying tissue is distinct. It happens, however, if the prolapse 
has existed for years without treatment, that the epithelial cones lying 
between the papillae grow deeper and infiltrate the upper layers of the 
stroma in. network form; we then have an "atypical growth of epi- 
thelium," according to Friedlander. Such a genuine growth of epi- 
thelium is very rare in this part. On the other hand, in hypertrophy of 
the epithelium illusions are easily produced in certain sections which 
easily give the impression of a real ' ' atypical growth of epithelium ' ' ; for 
Avhen the section is not made perpendicular to the surface, but obliquely 
or at a tangent, then those specimens in which the base of the papillae is 
cut transversely or obliquely shoAV a remarkable picture containing iso- 
lated epithelial masses and transversely cut papillae. The practised 
eye recognizes from the arrangement of the cells, from their normal re- 
lation to each other, and from the condition of the other tissues, whether 
a neoplasm or an oblique section is under observation; to the inexperi- 
enced a proper diagnosis of such sections causes great difficulty. Facts 
teach us that it is rare, very rare, that these epithelial hypertrophies in 
prolapse lead to carcinoma. On the contrary, it seems as if this firm 
epithelial armor furnishes a splendid protection to a prolapsed uterus 
w^hich is especially liable to irritation. At least I have never seen a 
<iarcinoma result from these benign epithelial hypertrophies in prolapse. 
It is, however, not impossible that a carcinomatous uterus may pro- 
lapse, or that a prolapsed uterus may occasionally become carcinomatous. 

Of the partial hypertrophies of the mucous membrane on the outer 
surface of the portio must be mentioned 

(0) Condylomata Acuminata. 

The pointed condylomata, as is known, occur most frequently upon 
the external genitalia as a result of gonorrhea, and as a rule are confined 
to those parts. Nevertheless it is observed that at times they extend 
further into the vagina and give it an irregular surface, which bleeds 
-easily on touch. In rare cases they extend up to the portio vaginalis 



CONDYLOMATA ACUMINATA, 51 

and form there the well-known warty excrescences, especially during 
pregnancy. These would have no further interest, from the standpoint 
of examination, if they always showed a typical appearance and if we 
knew the previous history. Even on the external genitalia it is not rare 
to find that several pointed condylomata have united into a tumor the 
size of a hazel-nut, forming a mass which has an ulcerating surface, 
bleeds easily, or discharges a purulent secretion. This makes the diag- 
nosis difficult, and the same thing occurs upon the cervix. Here, how- 
ever, greater difficulties in recognizing the affection arise, for the process 
on the external genitalia and in the vagina may have run its course, 
while it persists on the vaginal portion only. We then see not only a 
tumor with an ulcerating surface, but one which projects above the 
surface of the portio, which is hard to the touch and bleeds easily. A 
coexisting gonorrheal urethritis is, of course, no proof of the nature of 
the tumor on the cer\dx. Therefore a microscopical examination alone 
can make a diagnosis positive. In excising the tumor one must not fail 
to remove the matrix of the vaginal portion of the cervix likemse, in a 
wedge-shaped piece, and to make the excision so that a portion of the nor- 
mal mucous membrane is included. The resulting wound is easily closed 
with a suture. This test excision is therefore rather extensive, but the 
procedure is harmless, and the advantage for a positive diagnosis is de- 
cided. 

In a section made through the entire tumor perpendicular to the 
surface, it will be at once seen that we are dealing with a harmless epi- 
thelium tvhich shoics no tendency to penetrate deeply. The entire tumor 
is caused by an enormously increased formation of squamous epithelial 
layers, Avhich rest upon the numerous branched papilla like a fungus. 
These branches make it possible that an ideal vertical section cannot be 
obtained. The papillae and the squamous epithelium are then seen in 
the sections in every possible plane (see Fig. 8). It has already been 
mentioned in the paragraph on "Illusions" that in this manner illu- 
sions may result to the unpractised eye, and that a horizontal section 
through epithelium surrounded by other tissue may easily be mistaken 
for a carcinomatous alveolus. I repeat again that the normal arrange- 
ment and the normal appearance of the cells of the squamous epithelium 
is an all-important factor in judging a section. This is especially to be 
observed when only a small piece has been removed for examination. 
If, on a section through the entire tumor surrounded bj^ normal tissue, 
this tumor be seen elevated like a fungus icithout penetrating into the 
deeper lying structures, there is no doubt that we are dealing mth a 
benign epithelial neoplasm, no matter how large the latter may be. If 
the condyloma be ulcerated-^, this surface has the appearance which we 
have studied in discussing the true ulcers of the vaginal portion. 

(h) Hypertrophy of the Stroma. 
This is in some cases a diffuse hypertrophy, i. e., one or other of the 



52 ELONGATIO COLLI. 

lips of the cervix, or both, become hypertrophic, whereby a decided 
lengthening and thickening takes place (cervix hypertrophy, elongatio 
colli). In other cases there is only a circumscribed hypertrophy of 
certain areas, a so-called "polyp." 

(«) Elongatio CoHi. 

In hypertrophy of the cervix all the elements forming this part are 
affected. A microscopical section contains all those elements which we 
have learned in viewing normal conditions. Most noticeable is the 
enormous increase of the fibrous connective tissue, which may occupy the 
entire field. Hand in hand is an enlargement of the vessels which in 
some cases is decidedly surprising. The cellular elements of the con- 
nective tissue are least represented ; these probably are destroyed through 
the pressure of the newly-formed connective tissue. What the causes 
for the development of such an unusual growth may be has not been de- 
termined. It may become so decided that the cervix projects as far from 
the vulva as in a completely prolapsed uterus. An elongation would of 
itself have no further diagnostic interest, were it not that, as a result 
of the protrusion of the cervix from the vulva, the same ulcers may de- 
velop as in prolapse. Through the coexisting hypertrophy of the con- 
nective tissue the presenting part often feels as hard as stone. This, in 
conjunction with an easily bleeding ulcer which produces fetid secretion, 
makes it impossible to say at first whether a carcinoma is or is not pres- 
ent. It is therefore necessary, before taking any operative steps, to make 
a test excision. 

The ulcers, as well as the epithelial covering of the non-ulcerated 
parts, resemble those found in prolapse. Yet even among these hyper- 
trophies carcinomatous ulcers have been reported. I myself have as yet 
not had the opportunity of observing such. 

(/?) Cervical Polyps. 

To avoid any misunderstanding as to what is understood by cervical 
polyps, I should like to give an exact definition of the same. Literally, 
cervical polyps are polyps of the neck of the uterus. That under polyps 
we mean pedunculated growths {i.e., only the form is described), re- 
quires no special mention. A polyp may possess a thin pedicle of various 
lengths formed by the tissue matrix, or may be attached by a broad 
base. In either case the pedicle must be well defined from the matrix 
from which the neoplasm issues. For that reason we must make a sharp 
distinction in the cervix between absolute growth (elongation of the 
cervix, cervix hypertrophy) and partial growths (cervical polyps). 

Anatomically three forms of polyps may be distinguished in the vag- 
inal portion of the cervix : 

1. Polyps originating from the external squamous epithelial surface 
of the cervix. 

2. Those which are formed at the junction of the squamous and cyl- 
indrical epithelium. 



CERVICAL POLYPS. 



53 



3. Those which originate in the cervical canal and, therefore, from 
a surface covered entirely with cylindrical epithelium. 

According to its origin such a cervical polyp has as a covering squa- 
mous epithelium or cylindrical epithelium, or both. 

Corresponding to its epithelial covering, a polyp possesses the stroma 
of that tissue from which it originates, and represents simply an ex- 
cessive circumscribed growth of an existing tissue. Just as the elements 
normally present in the originating matrix are here represented, so like- 
wise may be found in polyps such formations as are frequently found 
in the originating base of the polyp, without their being considered as se- 
rious pathological changes. In the cervix these are, as we have seen, 




Figure 16. — Polyp of the Cervix (originating from the vaginal surface). 

a, squamous epithelium ; h^ stroma infiltrated with small cells ; c, cystic spaces, dilated 
glands ; d, spaces lined with cylindrical epithelium. 



mainly glandular neoplasms. Therefore, if a polyp originates from the 
outer surface of the vaginal portion, it will show a covering of squamous 
epithelium if the area from which it originated was normal. In addition, 
it will consist of a stroma containing numerous connective-tissue cells, 
fibrous connective tissue, and vessels. The latter are especially well de- 
veloped in the pedicle, so that here all the other 'tissues are in the back- 
ground. The increase in the vessels is also present on the surface of a 
polyp, where turgid capillaries are often found. 

From this we understand why such polyps bleed easily on touch, and 
why dangerous bleeding after removal of such polyps and secondary 
hemorrhage may occur, if the pedicle be not properly treated. 



54 



CERVICAL POLYPS. 



If in the stroma there be found spaces lined with cylindrical epi- 
thelium, this condition cannot be considered unusual in view of our ex- 
planations given above. 

In the same way polyps which originate from the cervical mucous 
membrane may contain, like the latter, numerous glands as their main 
constituent. And since in polyps we are dealing with a process of hyper- 
trophy, it follows naturally that these glands are partly enlarged and 
changed in form, and partly show a great increase in number. In some 
cases the polyp may consist almost entirely of glands with very little in- 
terstitial tissue {adenoma polyposum, or polypoid adenoma), so that it 
seems, on transverse section, cribrated like a sieve. In rare cases myxo- 
matous degeneration of the connective tissue is observed in these latter 
forms, which causes the formation of a tumor called myxadenoma poly- 
posum, or polypoid myxadenoma. 

From the above description of their mode of origin, it is clear that no 




FiorRE 16a.- — Ceetical Poltp (originatiny from the mucous memtrane of the cervix). 

a, cylindrical epithelium of the surface ; !>, glands lined with cylindrical epithelium ; 
c, glandular depression of the surface cylindrical epithelium (epithelia i?ast off). 



great weight is to be laid upon the fact that one-half of the surface of a 
polyp may be covered with cylindrical epithelium, while the other half 
has a covering of squamous, for normally these two forms of epithelium 
border on each other. It would be fundamentally wrong if this condi- 
tion in a polyp were to be judged otherwise than the same condition in 
the tissues from which it arises. The hypertrophy of the stroma of a 
polyp may naturally be imparted to the epithelium, and then the same 
changes result as we have learned may occur through irritation of the 
epithelium in prolapse and in the case of elongation of the cervix. A 
thickening of the epithelium may readily develop on the surface of a 
polyp covered with squamous epithelium, especially if the polyp is so 
long that it projects from the vagina. The projections of squamous epi- 
thelium may sink deeper than normally into the underlying tissue, with- 
out giving us the right to conclude, as is frequently done, that we are 
dealing with a ''beginning carcinomatous degeneration of the cylindrical 
epithelium." 



CERVICAL POLYPS. 



55 



We now come to the special consideration of these polyps in a mi- 
croscopic diagnostic relation. Every clinician has had the experience 
that such polyps, especially those which under the microscope are found 
to contain numerous glands, at times recur after simple removal. The 
return of a neoplasm is always a symptom not to be undervalued. 

Since this question is important, I quote literally the remarks of two 
authors who have had great experience in this matter. 

Gusserow says •} "The only symptom which these conditions (polyps) 
cause is bleeding— bleeding which at first follows the type of menstrua- 




FiGURE 17. — Cervical Polyp. 

a, cysts whose walls are partly lined with cylindrical epithelium and partly are de- 
prived of epithelium ; 6^ dilated glands ; c, horizontal section through a squamous epi- 
thelial group ; d, squamous epithelium which above is stretched very thin —numerous sec- 
tions through vessels in a stroma infiltrated with small cells. 



tion and is only characterized by the amount of the logs of blood, and 
later, lasting always longer, becomes a seemingly irregular bleeding, 
which in this way may lead to a high degree of anemia. What makes 
this affection, however, still more serious is its tendency to recur, as well 
as the undoubted fact that it leads, in a large number of cases, to car- 
cinoma of the uterus, usually carcinoma of the body. Such observations 
have been made by Breisky, Schroder, Maslowsky, Winckel, Schatz, and 
others. From the cylindrical epithelium of the newly-formed glands 
growths extend into the lumen of the glands and into the stroma, and the 
glands are in this way filled with cells, and there occur in the deeper 

iBillroth-Lticke: Text Book. 



56 CERVICAL POLYPS. 

layers of the mucous membrane, and later in the muscularis, atypical 
cell groups in the glandular spaces. This course is the more to be feared 
the sooner after single or repeated removal of the adenomatous growths 
they return, and the nearer the individual approaches the climacterium 
or the further she has passed it. ' ' 

Williams' expresses himself in a like manner: 

''The polyp was 1.8 centimetres long, 1.25 centimetres wide in its 
greatest diameter, and had a thin pedicle. It was cut in its entire length 
and examined microscopically, whereby a remarkable and noteworthy 
condition was found. The lower and broader end of the polyp was cov- 
ered with a layer of carcinomatous squamous epithelium, which sent pro- 
longations into the stroma of the tumor, and which penetrated several 
gland ivalls. Above the point at which the carcinoma ended the surface 
of the pedicle was covered with cylindrical epithelium, in which numer- 
ous ducts of glands opened. The pedicle was perfectly normal. 

"We were dealing, without doubt, with a mucous polyp which had 
arisen from the mucous membrane of the cervical canal. The deeper 
part, projecting from the external os, seems to have taken on squamous 
epithelium, while the remainder retained its original covering of cylin- 
drical epithelium. 

'^Polyps of the uterus in an advanced stage have a tendency to he- 
come malignant, and therefore every one should he examined histo- 
logically as to its true nature after removal." 

The fact that such polyps may become carcinomatous is to be con- 
sidered as positive. The question is : what positive evidences do we 
possess to enable us to diagnose such a carcinomatous degeneration as 
early as possible? 

Each of the authors whom I have quoted gives a different cause for 
the occurrence of carcinoma in these polyps. Either it originates from 
the surface epithelium or from the epithelium of the glands. 

As we have seen, the cervical polyps are sometimes covered with the 
one and sometimes with the other form of epithelium, and sometimes 
with both forms. So long as a polyp is covered with cylindrical epi- 
thelium the occurrence of a carcinoma in it is very rare. It is different, 
however, with the squamous epithelium. It has long been known that 
squamous epithelium, as a result of irritations as yet unknown, forms 
growths and sends projections into the underlying tissue, which gro^vths 
penetrate into the glands and hreak through the vessel walls, without 
respecting the borders or limits of these tissues, and, in a word, become 
a carcinoma. This diagnosis cannot, however, be made if the squamous 
epithelium is only, as compared with the normal condition, thickened, 
and if perhaps a few epithelial projections have really penetrated a little 
deeper into the stroma ; for we have already called attention to the fact 
that associated with a polyp there is a general hypertrophy of all the 

iWilliams: Carcinoma of the Uterus. 



CARCINOMA OF THE CERVIX. 57 

formations naturally fonnd in the tissue. We should therefore not be 
surprised if the squamous epithelium joins in this change and becomes 
hypertrophic. The conditions in this case are exactly the same as those 
which we recognize in that of prolapse and in elongation of the cervix. 
Nowhere else are so many errors possible ; illusions are produced by 
the plane of the sections and easily give rise to error, for the polyps 
frequently show a very irregular surface, so that a section ^ of the 
squamous epithelium may be vertical, oblique, or tangential. In the diag- 
nosis of this condition special consideration must be given to this fact, 
and I therefore refer to the chapter on ' ' Illusions. ' ' The criteria which 
we follow in making the diagnosis ''carcinoma" will be fuUv discussed 
in the chapter on that affection. 

In the same Avay mistakes may occur in making the diagnosis of 
glandular carcinoma ; for it is just in hypertrophic formations that we 
find as a result of increased nutrition hyperplasia of the cylindrical 
EPITHELIUM. This is shown by an increase of the glands or by a growth 
of the epithelium in the glands. It is not rare to find the gland spaces 
lined with three or four layers of cylindrical epithelium; yet it is in- 
correct to diagnosis a beginning carcinoma from this condition alone, be- 
cause an increase of gland epithelium may be simply the result of a 
benign hyperplasia. That oblique sections, together with inflammatory 
changes which make the gland limits indistinct, may cause difficulty in 
diagnosis, requires no further special mention. 

It may be seen from this discussion that in judging whether such a 
polyp has undergone carcinomatous degeneration or not great difficulty 
may be found. This can only be decided if a clear idea is had of what 
a true carcinoma really is, and if its appearance, and the fact that 
it penetrates into tissue affected by it, be remembered. To make these 
conditions clear is our next task. I should prefer, before closing this 
chapter, to emphasize again that we cannot be careful enough in the 
diagnosis of a "beginning carcinomatous degeneration. 



J 5 



2. Carcinoma of the Cervix. 

The numerous anatomical works on carcinoma of the uterus which 
have been published in the last decade have not essentially advanced our 
knowledge of the nature of this affection, while, on the other hand, they 
have been of the greatest value in determining our present views as to 
its treatment. According to the microscopical examinations of Ruge 
and Yeit, Schroder distinguished between (1) a superficial cancer of the 
portio vaginalis, which develops on the mucous membrane of the vaginal 
portion, and which has very little tendency to extend to the lining of the 
cervix, and (2) carcinoma of the cervix, which begins as circumscribed 
carcinomatous nodules under the mucous membrane, and then either 
extends to the outer surface of the vaginal portion or breaks into the 
cervical canal. From this Schroder formulated the axiom that in the 



58 



CARCINOMA OF THE CERVIX. 



first case, so long as the carcinoma is confined to the vaginal portion, in- 
fravaginal amputation of the cervix should be performed, while supra- 
vaginal amputation should be performed so soon as the carcinoma has 
extended to the vaginal tissue. Recent investigations, on the contrary, 
have taught us that such a schematic division cannot be carried out, but 
that in cancer of the vaginal portion carcinomatous changes occur in 
other parts of the uterus and pelvis much more frequently than was for- 
merly believed. When Schroder says that in the treatment of carcinoma 




Figure 18. 

&, carcinoma in a vein (a)j at some distance from the carcinoma centre ; c, trans- 
verse section of an artery with very thick wall ; d^ tangential section through a vessel ; 
e, muscular tissue. 



of the cervix the important step is a radical removal of the carcinoma, we 
now understand by that statement a total removal of the entire organ. 
Even though the results, so far as recurrence is concerned, are still poov, 
the cause of this is the fact that carcinoma is perhaps to he considered a 
local affection only in its earliest stages. If it exist for some time, as is 
usually the case when the patients are made cognizant of it by certain 
symptoms, it is then impossible for us to say with certainty whether ele- 
ments of the carcinoma have or have not already been carried further 



CARCINOMA OF THE CERVIX. 59 

through the blood or lymph channels, and these elements, in spite of the 
most extensive operation, may give rise to a recurrence in seemingly 
healthy pelvic tissues. I cannot refrain from mentioning an unusually 
characteristic case which came under my observation. A thirty-seven- 
year-old patient suffered only two months from irregular bleedings 
and discharge. Local examination disclosed a carcinoma of the anterior 
lip of the cervix, which seemed to be confined to this area alone. Neither 
the vaginal wall nor the parametrium was affected or showed any signs 
of involvement. Total extirpation through the vagina was easily carried 
out in the absence of complications. As much as possible of the broad 
ligament was removed, so as to he certain of having operated in healthy 
tissue. The specimen was subsequently, as is always the case, subjected 
to close microscopical examination. It was found that far from the 
carcinoma, in an otherwise healthy-looking area^ a carcinomatous 
alveolus had made its way into a vein, as is clearly seen in Fig. 18. 

This instance is proof again that one cannot operate too radically^ 
and that it is certainly useless to remove only a portion of the uterus. 
The time is certainly near when the few partisans of partial extirpation 
will decide, as a result of anatomical facts, upon removal of the entire 
organ. . 

I should not have entered upon the discussion of these clinical con- 
ditions if the same were not of importance to the microscopist. At the 
moment at which we remove the entire uterus because of the microscopi- 
cal diagnosis ''carcinoma," it is no longer the duty of the microscopist 
to decide whether the carcinoma is only superficial (which is only pos- 
sible in the very early stages) or is a deep cervix carcinoma. His duty is 
only to decide whether or not carcinoma is present; for if once the 
microscopical diagnosis "carcinoma" is made the therapeutic action 
of the clinician is indicated, namely, total extirpation of the uterus. 

We will discuss in the following chapter the question as to when we 
are justified in making the diagnosis carcinoma, without discussing the 
finer anatomical questions, the mode of development, the channels of 
extension, etc. 

Carcinoma of the cervix appears in two very different forms. Either 
it takes its origin from the squamous epithelium of the vaginal portion 
or from the glands of the cervical mucous membrane, and then destroys 
the neighboring tissues, especially in the latter instance, before it pene- 
trates to the outer surface. 

In the first form the carcinoma has a decided tendency to idceration, 
so that we may with justice speak of a carcinomatous idcer. In viewing 
the cervix through the speculum we see in these cases, as a rule, a very 
red irregular surface which bleeds readily when touched with the sound. 
Sometimes one lip, sometimes both lips of the cervix are affected. In 
contrast to the usual form of ulcers, the ulcerating carcinomatous sur- 
face does not lie helow the surface of the cervix, but projects above it 



60 CARCINOMA OF THE CERVIX. 

(not to speak of tJiose cases in which, a large tumor partly fills the 
vagina). When the neoplasm has grown to the latter extent, no micro- 
scopical examination is necessary in order to form a diagnosis, for here 
our clinical experience is quite sufficient. It is different when we are 
dealing with a 'beginning carcinoma of the cervical canal, for here the 
appearance through the speculum does not necessarily show any change. 
The squamous epithelium covers the surface as in normal cases, so that 
on inspection we seem to be dealing with a healthy organ. Here the 
history of the case and palpation are of decided value, for usually the 
examining finger can pass into the cervical canal and feels soft masses 
more or less easily removed with the finger. 

It is naturally plain that the course of the microscopical examina- 
tion would vary according to the nature of a case. If an ulcer, sus- 
picious because of its clinical course, be found in the cervix, a test ex- 
cision from the suspected area should be made for diagnostic purposes. 
It is better to choose a part which shows a transition from the ulcerat- 
ing surface to apparently healthy tissue. It is urgently advised not to 
excise too small a piece, and for that reason it is better to use forceps 
and a knife than the curved scissors, with which, as a rule, small super- 
ficial pieces are removed. The wound should always be closed by deep 
sutures; and I advise that this step should not be an ambulatory one, 
since even w^ith greatest care a severe hemorrhage may result if ab- 
solute quiet be not enjoined. 

If the surface shows no changes pieces of the tumor must be re- 
moved with a sharp spoon, after having first attempted to obtain material 
for examination from the cervical canal with the finger. The curetting 
should not be done blindly, but after introduction of the speculum and 
fixation of the uterus with the volsellum. The material obtained must 
be prepared as described in the first part. I advise, when making such 
important examinations, the embedding in celloidin, so that many and 
good sections may be made, and that a portion of the specimen be cut 
with the freezing microtome according to the method of Pick or 
Benda. , 

Although I suppose that the general appearance of a carcinoma is 
known, I desire to discuss in a few words the accepted definition of the 
same. We understand by carcinoma a tumor or neoplasm of epithelial 
elements in a connective-tissue matrix. The epithelial elements lie in this 
groundwork in larger or smaller groups and form the so-called ' ' carcino- 
matous alveoli " or " cancer nests. ' ' Even though this is a fairly exact de- 
scription of the anatomical form, it alone does not suffice to make this 
weighty diagnosis, for we have repeatedly seen in our previous discus- 
sions that such epithelial nests may occur in a tissue without cancer 
being present. I call attention to the pictures we find in pointed con- 
dylomata, and to the hypertrophies of epithelium, and to the ''illusion 
pictures ' ' resulting from the plane in which the sections are cut. There 



CARCINOMA OF THE CERVIX. 61 

belongs, therefore, to a definition of cancer something else, and something 
equally important. This is the relation of the growth to the tissue which 
it penetrates. A carcinoma does not displace the other tissue structures, 
but advances irregularly and is atypical in form, and is not stopped by 
other tissues. It destroys the gland borders and the vessel walls, and 
penetrates into the muscular tissue until finally nothing is left of the 
original tissues. The latter does not remain without reaction; it reacts 
to the invading neoplasm, in the early stages, mth a small-celled in- 
filtration, more marked, perhaps, than occurs in any other affection in 
the cervix. 

Before I pass to the microscopical condition in cancer of the cervix, 
I w^ould discuss in a few words the so-called "carcinoma alveoli." In 
general it is said that the cancer alveoli are made up of epithelial cells. 
In my opinion this definition is not sufficient, for the beginner easily 
gains false \aews as to the appearance of these alveoli. He must know 
that these cells do not possess the same regidarity in size and position 
found in tlie case of cells forming normal epithelial tissue. 




Figure 19. — Cells of a Caecixomatous Alveolus with so-called " Protozoal " 

Contents. 

What is really striking is the irregularity in the size and form of the 
cells. From small cells, of the size of the white corpuscles, all stages 
are found up to the largest cell forms. The nuclei are, as a rule, larger 
than normal nuclei of squamous epithelium, and the cell body surrounds 
the nucleus sometimes Avith less, sometimes A^dth more protoplasm. 

The nucleus shows great differences in form. In addition to simple 
nuclei there are often found in one cell two, three, or more nuclei, i.e., 
numerous nuclear fragments. 

If the specimens are properly fixed there is frequently seen a decided 
segmentation of the nucleus, to which recently special attention has 
been called by several authorities. There may be observed so-called 
"cell— i.e.^ nuclear— inclusions, " which are considered by some investi- 
gators to be protozoa. In Fig. 19 I have drawn such cells. It may be 
seen from this illustration how the carcinoma cells may differ in size. 
This is shown still more clearly by Fig. 20, in which a cancer alveolus is 
seen strongly magnified. 



62 



CARCINOMA OF THE CERVIX. 



Here may be seen the absence of such regularity in the arrangement 
of the cells as is usually found in normal epithelial tissue. It may be 
seen that there is a confusion of large, larger, and smaller cells, between 
which are a few capillaries, a condition not occurring in normal epithe- 
lium. It is also noticeable that the cells do not always lie side by side, as 
in Fig. 20, but that very often leucocytes are found between these cells 
<Fig. 21). 

After this description, we may define carcinoma as follows: Car- 




FiGUEE 20. — Cancer Alveolus by High-power Lens (fixed in Mchloride) . 

a, mononuclear cells ; &, very large cells with bubble-like cell contents ; c, capillary 
filled with blood. 



cinoma is a neoplasm which consists of a tissue groundwork, more or 
less rich in cells, in which groups of various large epithelial cells are 
lodged. The latter form cords and penetrate the tissue, which they 
enter irregularly and in every direction. These cords are sometimes 
formed of a few cells, and sometimes of large masses. They break 
through other tissue layers and tissue forms, whose boundaries are de- 
stroyed by the epithelial cells entering them. They increase in this way 
until finally nothing is left of the original tissues. A carcinoma finds no 
limit at the muscular layer, breaks through the vessel walls, and de- 



CARCINOMA OF THE CERVIX. 



63 



stroys the gland boundaries ; in a word, it does not remain confined to any 
one tissue, but grows without limitation through various tissues. 

These are the essential points, in my opinion, in making a diagnosis 
of carcinoma, whether it occur in the uterus or in any other portion of 
the human body. If these are established we may be certain that we shall 
not confuse a carcinoma with a benign epithelial hyperplasia or mth an 
"illusion picture." In the latter cases the uniformity of the change, 
the regular arrangement of the elements, will always furnish the correct 
evidence as to the character of the change. Attention must be again 
called to the fact that the growth of epithelium within the gland lumina 
2.9 in no wise a justification for the diagnosis of a beginning carcinoma 
so long as the boundaries of the glands are not affected by the epithelia. 




FiGL'RE 21. — CAIlCI^'OMA OF THE Vagixal Portiox OF THE Uterus (explanation in test). 



What the very beginning is we do not yet know ; we shall no doubt learn 
even this when we learn the cause of carcinoma. Until then we must 
hold to the complete picture of a carcinoma, as we have given it above, 
in malring a diagnosis. 

These facts will be made use of in judging a test excision from the 
vaginal portion, the microscopical picture of which is to be found in 
the above illustration (Fig. 21). The section is so chosen that we see 
the transition from squamous epithelium to the affected tissue. 

On the right side of the figure is seen the squamous epithelium (a) 
which forms the normal surface. This squamous epithelium shows al- 
ready a de^dation from its usual quality. As may be seen in the larger 
sections, in which more tissue can be observed, the squamous epithelium 



64 



CARCINOMA OF THE CERVIX. 



becomes decidedly thicker in the direction of the carcinoma. The same 
is true in this section. In place of relatively few layers, as mentionea 
in the discussion of the normal condition, the squamous epithelium is 
seen to sink considerably into the underlying stroma. The nearer we 
go to the small-celled infiltration the more do the limits of the epithelial 
cells disappear, and it may be observed, above and to the left, that 
numerous leucocytes are forcing their way between the individual epithe- 
lial cells. Whether the spaces (h) are artificially caused by cutting or 
whether a pathological process is present cannot be stated vs^ith cer- 
tainty. Near the squamous epithelium is found a tissue which shows 
a very marked small-celled infiltration. The same extends to the surface 




FiGUEE 22. — Caecinoma of the Cekvix (general view). 
a, carcinoma alveoli ; 6^ interstitial tissue. 



as evidence of the presence of an ulcer. In this tissue are seen two 
large groups of lighter cells (c), between which are found darker-stained 
round structures. The larger cell groups are composed of cells of va- 
rious forms; those on the periphery are, as a rule, smaller than those 
situated centrally. We are dealing here with two large typical cancer 
alveoli. If we examine the areas infiltrated with small cells more closely 
we find at various points (d, d^, d^,) again isolated groups of cells whi^h 
are sharply marked off from the small- celled infiltration; these are 
smaller cancer nests. It may be seen, therefore, that the entire tissue is 
quite changed in character. Of the normal constituents of the cervical 



CARCINOMA OF THE CERVIX. 



65 



tissue none is present in the section, and we need not hesitate to diagnose 
a carcinoma with certainty from such a picture alone. If we study the 
specimen further (though this cannot be illustrated in a drawing) we 
find that such cell nests infiltrate the remaining cervical tissue, and that 
the small-celled infiltration extends still further into the deeply situated 
parts. In this specimen nothing can be seen of the connective-tissue 
groundwork, since everything is covered by the enormous small-celled 
infiltration. This is, however, as already mentioned, characteristic of 
the reaction of tissue to a neoplasm in the early stages. If the process 
had existed a longer time we should have found more fibrous connective 




Figure 28. — Gland whose Wall at one side is Destroyed by Carcinomatous Changes. 

a, dark i-ound structures ; h, normal epitlielia which have retracted from the surround- 
ing tissue ; c, carcinoma wiiich has, on tlie right, broken through the wall. 



tissue in place of the exclusive small-celled infiltration. Such typical 
pictures of carcinoma are already well known from the text books on 
general pathology. Therefore I have given in Fig. 21 a view rarely 
seen in schematic drawings, but one which is often met with in micro- 
scopical sections. Fig. 22 serves as a general view with a lower power. 

It shows by low power how the cervix is for the most part destroyed 
by the neoplasm ; perhaps the connective-tissue groundwork may be con- 
sidered the remains of the stroma of the vaginal portion of the cervix. 

In the same way a carcinoma originating in the cervical canal is to be 

judged. The same characteristics are necessary in making a diagnosis, 

for the presence of glands in this part does not change this feature. As 

a rule Ihe glands are increased in number in carcinoma without many 
5 



<'^6 MALIGNANT ADENOMA OF THE CERVIX. 

changes in them being evident. Sometimes it is seen that the gland 
walls are lined by a stratified layer of cylindrical epithelium. This 
alone, as we have often remarked, is not sufficient ground for the diag- 
nosis ''carcinoma" if the other requisites he not fulfilled. One of the 
most important of these requisites in the case of glands is the destruction 
of the gland borders. 

If we find a picture like Fig. 23, no further proof is necessary of the 
destructive character of the process, for it is seen that one side of the 
gland is entirely destroyed by the entering neoplasm. Boundless 
growth through various tissues we have already given as an important 
evidence of the malignancy of a neoplasm. 

3. ]\Ialignant Adenoma of the Cervix (Adenoma Destruens). 

If firm cancerous prolongations are not formed and only the glands 
are found to be increased to an enormous extent, destroying all the in- 
terstitial tissue, the malignancy of this process (adenoma) will only 
then be microscopically proven on observing the relation of these glands 
to the muscular tissue. If the latter is also destroyed by these glands 
there is no doubt as to the diagnosis. If the growth of glands is, however, 
confined to the mucous membrane, although the glands may be exceed- 
ingly numerous, the process is not necessarily malignant. Only when 
the glandular type is no longer preserved, and when cords of atypieally 
arranged cylindrical cells substitute the original tissue, are we justified 
in making the diagnosis of a destructive adenomatous neoplasm. I 
should not like to make any fast rules to govern the beginner in such a 
case, since the diagnosis of this affection requires great practice, and 
even the experienced pathologist often finds difficulty in properly con- 
struing such specimens, especially if he is furnished with only curetted 
particles and not the entire organ. The coexisting clinical condition 
and symptoms are of great weight, and often everything must be fully 
.considered in deciding the practical management of such a case. Under 
pathology of the endometrium we will consider these relations more 
fully. In the cervix the occurrence of a pure malignant adenoma with- 
out carcinoma is rare. In the course of the last few years a few such 
cases have been reported. Rather more frequently combinations of 
adenoma and carcinoma (adenocarcinoma) come under observation. 

4. SARCOMxi OF THE CeRVIX. 

Sarcomata occurring in the cervix are always circumscribed tumors, 
whether they are pedunculated (the polypoid form) or whether they 
grow far into the muscle. Macroscopically a sarcoma may look like a 
carcinoma, especially like that form called a "cauliflower growth." A 
decision as to whether it is a carcinoma or sarcoma requires a microscopi- 
cal examination. 



SARCOMA OF THE CERVIX, 67 

Sarcoma, as is known, originates from the cells of the connective 
tissue and is made up of closely arranged, round or spindle cells. A 
complete separation of these two forms can usually not be made. Giant 
cells are also found. A fine connective-tissue net lies between the cells. 
It shows at times a strong edematous infiltration or else a myxomatous de- 
generation. Thus the individual papillary formations are swollen, and 
from these results the cauliflower-like growth, so that the entire tumor 
has a racemose appearance (sarcoma botryoides). In the harder central 
parts of this neoplasm and in its base are found normal areas of 
connective tissue rich in blood, and nests or strands of sarcoma cells, 
while the peripheral parts resemble young connective tissue or mucous 
tissue. If the surface is not ulcerated it is usually covered mth one 
or more layers of cylindrical or squamous epithelium, depending on 
whether the tumor originates from the mucous membrane of the cer^dx 
or of the vaginal portion (Pfannenstiel, Pick). Between the sarcoma 
cells remains of the cervical glands may be found. 

The Origin of Sarcomata of the Cervix. 

The sarcomata of the cervix, as is the case in other organs, may 
originate from the various elements present in the matrix. They arise : 

((X.) From tlie Upper Layers of the Mucous Membrane. 

and then form especially grape-like tumors. These, as a rule, are rare ; 
they may reach a considerable size and grow entirely outside of the 
vagina. The occurrence of such tumors is observed in adults and also 
in children. At times there develops, in a carcinoma, an adenoma out 
of the remaining epithelium of the cervical mucous membrane, i.e., the 
glands, so that a mixed tumor results (adenosarcoma). If the connective 
tissue is myxomatously degenerated there results an adenomyxosarcoma. 
If. in addition to the glandular formation, cvstic structures also are 
found, Ave speak of a cystic adenosarcoma. From an adenosarcoma there 
may easily result a transition into carcinoma, so that a form of growth is 
seen which is known as a sarcomatous adenocarcinoma. 
A second form of sarcoma results 

(p) Througli Sarcomatous Degeneration of a Cervical 3Iyoma or Fibroma. 

In this case the sarcoma cells are said to result from a direct trans- 
formation (metaplasia) of the myoma cells, or from the connective 
tissue between the muscle bundles. In most of these cases we are con- 
cerned with a pure spindle-celled sarcoma. 

Another special form of sarcoma is : 

{y) L,ynii}Uatic Endotlielioma. 

The histological picture of this form of sarcoma is almost identical 
with that of an adenocarcinoma, and is onlv to be disting'uished from 



68 TUBERCULOSIS OF THE CERVIX. 

it through its different origin. It is to be mentioned that, according 
to the views of several authors, the endothelium of the lymph and blood 
vessels is of entodermal origin ( ? ) . Then it must be considered epithe- 
lium, and the tumors resulting therefrom can therefore not be considered 
as belonging to the group of sarcomata. 

5. Myomata^ Fibromata^ Fibromyomata. 

More rarely than in the body of the uterus, there are found in the 
cervix benign connective- tissue neoplasms. These are situated either 
under the mucous membrane or may by further growth bcome peduncu- 
lated (polyps). They then fill the vagina and protrude from it; or there 
result enlargements, especially of the posterior cervical wall, which at 
times may fill the entire true pelvis. Rarely are we concerned in these 
tumors with histologically pure myomata or fibromata, but generally 
with fibromyomata, which contain muscle bundles between fibrous con- 
nective tissue. 

At times glandular and cystic deposits are found, as is the case in 
myomata of the body of the uterus (cystadeno fibroma of the cervix). 

As mentioned above, there may occur in these a sarcomatous degenera- 
tion (myosarcoma) and, as a rule, polj^poid formations. There has been 
described, in addition to the smooth muscle fibres, the presence of 
striated muscle fibres (leio- and rhabdomyosarcoma). (See Part III.) 

6. Tuberculosis of the Cervix. 

Primary tuberculosis of the cervix occurs infrequently, but I believe 
that with careful microscopical examination more cases will be found, 
since recently attention has been frequently called to its occurrence. I 
myself have had several striking cases which were of interest in various 
ways. The clinical symptoms and the appearance shown by the specu- 
lum were very much like those in carcinoma. There were profuse ir- 
regular bleedings, great discharge, and an ulcerated appearance of the 
cervix. Proof of the real nature of the affection is given only by the 
microscopical examination, which I carried out in my case because I 
suspected it of being carcinoma. The following picture (Fig. 24) shows 
that the surface is covered by nearly normal squamous epithelium (a). 
On the left side of the figure are seen the typical spaces lined with 
cylindrical epithelium, which we have learned to know in the case of 
the so-called "erosions." On the right side, on the other hand, are seen 
in the stroma several characteristic tubercles (c) with giant cells (d). 
The stroma is infiltrated with small cells in places, but shows no de- 
cided changes of any other kind. 

In a second case there was decided hyperplasia of the epithelial cells 
of the cervical glands, so that the glands were lined with several layers 
of cylindrical epithelium in' the stage of proliferation. If we consider 



THE UTERUS. 



69 



that in tuberculosis there may occur a growth of the squamous epithelium 
(Carl Friedlander 's atypical epithelial growth) with the formation of 
reticular strands in the subepithelial tissue, and if we reflect, on the 
other hand, that in carcinoma giant cells have also been described, it 
is evident that in striving for a very early microscopical diagnosis errors 
may easily occur. I am convinced that the uterus is frequently removed 
for '^ beginning carcinoma" where in fact tuberculosis is present, and in 
the future more attention must be paid to this point. The presence of 
tubercle bacilli, of so great importance in the differential diagnosis, is 
not, as a rule, demonstrated by the examination of test excisions. 




■♦•«-"'' '-.irv vv'.-; "■ " "■ ' * 



Figure 24. — Tuberculosis of the Cervix. 
a, squamous epithelium ; 6, glands ; c, tubercles with giant cells (d). 



IV. THE UTERUS. 

The body of the uterus is that portion which begins at the internal 
OS and extends to the fundus. It is composed of mucous membrane, of 
muscle, and of a peritoneal covering. The portion of chief interest is 
the mucous membrane, or endometrium, since by far the largest pro- 
portion of uterine affections originates therein, and, on the other hand, 
it is usually affected in most of the other pathological conditions of 
the internal genitalia. Since, further, the curettings of the uterus for 
diagnostic or therapeutic purposes consist almost always of only mucous 
membrane, it is of great importance that we become intimately ac- 
quainted with its normal appearance. It is more important here than in 
the cervix to recognize its normal composition, for there is no other tissue 
in the human body which, in its normal condition, is as liable to varia- 



70 THE ENDOMETRIUM AT PUBERTY. 

tions as the uterine mucosa. It is just as different at puberty and in 
advanced age as during and after menstruation, and as during and 
after pregnancy until the restoration to its original condition. 

It' is very easy for those who do not know these conditions to consider 
normal appearances as pathological. We will therefore discuss the vary- 
ing normal relations before passing on to the study of its pathological 
investigations. 

A. THE MUCOUS MEMBRANE OF THE UTERUS (ENDO- 
METRIUM). 

1. NORMAL ANATOMY. 

The mucous lining of the uterus lines the muscle wall which forms 
the hollow body of that organ. Externally the latter is bounded by a 
peritoneal covering. Under this, and so firmly united to it that it 
cannot easily be removed, lies a thin longitudinal muscle layer, which 
is followed then by a layer of richly developed elastic connective tissue. 
In this are found the blood vessels which supply the body of the uterus, 
and the branches which pass to the muscle bundles and to the mucous 
membrane, in which they end as a network of capillaries. The vessels 
running circularly are of considerable size. The arteries are remarkable 
for the thickness of their walls. 

The muscular layer which follows this vascular layer forms nearly 
the entire thickness of the uterine wall. It consists, according to the 
statements of certain text books, of an external longitudinal layer, of a 
layer of interlacing fibres, and of an internal circular layer whose fibres 
extend into the lowest layers of the mucous membrane. According to 
recent examination, such a schematic division cannot be countenanced. 
According to the sections which I have made, it appears that the main 
mass of the uterine muscle is formed by a circular layer, in which fibres 
running in other directions are present. Immediately under the mucous 
membrane a thin longitudinal layer of muscle fibres can be distinguished. 
The mucous membrane possesses no sub mucosa (Fig. 4). The thickest 
layer of the muscle has been called muscularis mucosae, and, correspond- 
ingly, the vascular layer has been called the real muscle. This view, 
however, stands quite alone, and has been rejected as unstable by recent 
investigations. 

(oc) The Encloinetrium after Puberty, in a State of Rest (i.e., between Two Menstruations). 

The endometrium lines the inner surface of the uterus in a layer 
one to two mm. thick. It is grayish, faintly shining, and of soft 
consistence. It consists of a stroma in which vessels run, and of the 
uterine glands. 

The stroma, i.e., the interglandular tissue, may be called ''lymphoid 



THE ENDOMETRIUM AT PUBERTY. 



71 



tissue." It consists mainly of rounded oval cells, of almost tlie size 
of white blood corpuscles, which lie in a very fine connective-tissue 
reticulum, which in comparison with the cells stands quite in the back- 
ground. 

The cells are not always oval, for around the glands and in the 
region of the muscular tissue there are some which are spindle-shaped. 
The cell boundaries themselves are recognized with difficulty in the 
specimens hardened in alcohol, for the nucleus occupies the greater part 
of the cells, and its membrane and transparent protoplasm lie so near 
the external limit of the cell that usually only this nucleus is seen. 




Figure 25. 

a, almost normal endometrium (slight increase in glands) ; 6, muscle — the boundary 
between muscle and mucous membrane is in this specimen very distinct. The surface 
is covered with cylindrical epithelium. The epithelia in the glands near the surface have 
fallen out. Gland openings do not appear in this section. 



On its inner surface, i.e., toward the cavity, the mucous membrane 
is covered with simple ciliated cylindrical epithelium. The mucous 
membrane is not sharply marked off from the muscle, for a gradual in- 
terweaving of mucous membrane and muscle fibres occurs. We find, 
therefore, muscle fibres in the deepest layer of the mucous membrane, 
and, vice versa, mucous membrane elements in the superficial muscle 
layers. 

The surface epithelium, whose cells are somewhat lower and broader 



72 



NORMAL ENDOMETRIUM. 



than those in the cervical canal, does not run uninterruptedly over the 
surface, but forms, at certain intervals, funnel-shaped depressions, which 
appear through a lens like punctate openings. These lead into the uter- 
ine glands, which are lined with the same epithelium as that found 
on the surface. 

The uterine glands are tubular glands which perforate the entire 
mucous membrane perpendicularly or obliquely, so that the fundus 
of these glands frequently lies in the superficial layers of the 













FiGUEB 26. — Almost Normal Endombtbium (highly magnified), 
a, surface epithelium ; b, longitudinal section through gland ; c, transverse and oblique 
sections of glands : d, interstitial tissue consisting mainly of oval nuclei (cell borders 
not evident) ; at e they are spindle-shaped ; at f a little more fibrous tissue is present 
between the cells than elsewhere ; g, invaginated gland. 



muscle wall. In their upper third the glands, as a rule, follow a 
straight course, while deeper they are often twisting and sometimes 
forked. In this way it happens that in sections perpendicular to the 
surface there are found in the upper layers glands in longitudinal sec- 
tion, while in the deeper layers they are seen transversely or ob- 
liquely cut. 

In such a microscopical picture are seen spaces lined with epithelium, 
some long spaces, others oval or circular. Since the glands often divide 



UTERINE GLANDS. 73 

deeper down and take a twisting course, we naturally find the gland 
lumina cut through more frequently there than where the glands run 
straight without dividing. In this way the impression may be given 
that a pathological increase of glands is present. A criterion in judging 
this condition is the number of glands in the upper layers, when seen 
by a lens of moderate power. 

The mdth of the gland lumen is variable ; a definite normal size 
cannot be expressed in figures. Frequently the lumen is so narrow 
that the epithelial cells of the opposing sides are in contact, so that 
the canal is narrowed. Still, a rather wide gland cannot be con- 
sidered pathological. At times the form is not symmetrically round, 
but, as in the case of the cervical glands, the interstitial tissue rises in 
places toward the lumen of the gland, so that an irregular form results, 
as well as a narrowing of the lumen. Not infrequently there is found 
in a gland lumen a second circle of epithelial cells, an evidence 
of invagination of the gland wall (Fig. 26, g). 

Attention is called to another condition. Very frequently the glands 
are separated from the interstitial tissue by an empty space which 
surrounds the gland wall in part or entirely like a crescent. This is 
caused by the varying action of alcohol on the stroma and the epi- 
thelium. The contraction of the epithelium is usually very even, and 
the contracted circle of cylindrical epithelium is so sharply outlined that 
from this fact alone the presence of a membrana propria may be taken 
for granted. In this way the glands are sharply defined from the other 
tissue. Another fact speaks for the presence of such a membrane. If 
a thin section be brushed in water the epithelial cells fall out, and there 
remain in the connective tissue only well-defined spaces, whose en- 
dothelial -like boundary can be recognized as a separate membrane. 
Quite different from these spaces, which normally are not present, are 
the falciform cavities or spaces which now and then separate a gland 
wall from the connective tissue. These are sections of capillary vessels, 
as a high-power lens shows the presence of an endothelial capillary wall. 

We now come to the discussion of the vessel distribution in the en- 
dometrium. 

The vessels, arteries, and veins, running in the muscle, branch more 
and more as they approach the mucous membrane, and form a capillary 
network in the latter layer. In only those parts lying near the muscle 
do we see in the mucous membrane isolated small arteries and veins. In 
the inner layers, on the contrary, only capillaries are present, whose 
blood surrounds the glands and flows through the other tissues. The 
number of venous capillaries is said to be far surpassed by the number 
or arterial capillaries. Since these are very narrow and thin they ap- 
pear indistinct except in injected specimens. There is often only a very 
fine space between two cells, which gives the impression that a cell is 
missing. Only through the presence of endothelia (by strong magnifica- 



74 THE ENDOMETRIUM DURING MENSTRUATION. 

tion) and the use of thin sections is it proven that in fact we are really 
dealing with capillaries. 

In addition to the blood vessels the endometrium possesses an ex- 
tensive network of lymphatics, concerning whose microscopical appear- 
ance there are as yet no reliable descriptions. It is generally said that 
the uterine mucous membrane, from the vaginal portion of the cervix 
to the fundus, is permeated in all directions by a lymphatic network 
with the very finest ramifications. How these look, whether they have 
walls of their own (which seems probable, according to the latest ob- 
servations), or whether they are only tissue spaces, or. whether they 
differ much from blood capillaries, or whether they contain valves and 
form dilatations or sinuses — all these are questions as yet unanswered, 
but of the greatest importance to normal and pathological anatomy. 

ift) Tlie Endometrium during- Menstruation. 

Regular menstruation, recurring every four weeks, which is to be 
considered as a discharge of blood from the uterine cavity, causes de- 
fined and regularly recurring changes in the mucous lining of the 
uterus. These depend in a great measure upon the blood vessels. 

In the normal endometrium, as has been said, we find great difficulty 
in demonstrating the capillaries. During menstruation, however, these 
are congested with blood, and frequently to such an extent that they 
may dilate to a very great size. 

Since the vessels do not open on the inner surface of the uterus, no 
outward bleeding can occur so long as they are only turgid. Such ex- 
ternal bleeding occurs only when the pressure is so great that a part 
of the blood is pressed out of the vessel channels and is poured out 
into the tissue. This occurs, in fact, in every menstruation. We find 
then in the interglandular tissue larger and smaller areas of free blood, 
which is also poured out between the meshes of the interglandular tissue, 
either pushing it aside or destroying it. The latter fact, doubted by 
many writers, may be recognized by finding inside of these blood ex- 
travasations cells of the original mucous membrane tissue, partly pre- 
served and partly degenerating. 

This blood, which is now no longer in its usual channels, trickles, 
under the constant pressure of the continually following outflow, wher- 
ever it meets with the least resistance. It passes between the epithelial 
cells and into the glands, completely filling them, or it flows directly 
through the surface epithelial layer into the uterine cavity, and from 
here is expelled by contractions of the uterus. 

This forcible penetration of the blood through the epithelial layer 
of the glands and of the surface causes, as may be readily understood, 
a shedding of epithelial cells. This shedding, however, never reaches 
such a degree that the surface is completely denuded of cells; only in 
isolated areas are these thrown off, and are found in the examination of 



THE ENDOMETRIUM DURING MENSTRUATION. 75 

the menstrual fluid among the red blood cells. That in this way the 
superficial layers of tissue may also sometimes be thrown out, especially 
the areas loosened by blood, deserves no further mention. 

In addition to red blood cells, white blood cells also naturally make 
their exit from the vessels. They lie in larger or smaller groups in the 
tissue, and are easily mistaken for areas of small-celled infiltration, with- 
out in reality an .inflammatory condition being present. The cells of the 
interstitial tissue retain, as a rule, their original form, but some may 
be destroyed by pressure and others may undergo fatty degeneration. 
No other changes are to be found during menstruation in a uterine mem- 
brane previously normal. 

It is the same with the epithelial cells. In spite of the great hyper- 
emia they do not proliferate, perhaps because the hyperemia as a rule 
disappears in a few days. On the other hand, changes from the normal, 
as a result of the great mechanical pressure, are also observed in these. 
We find many epithelial cells loosened from their points of attachment. 
They pass directly from the surface into the menstrual blood, or else 
fill the gland lumina and are then passed on into the uterine cavity 
through the excretory ducts. 

To recapitulate, the changes which are caused by menstruation, in 
the normal mucous membrane, are almost exclusively of a mechanical 
nature, consisting of a destruction of some cells of the interstitial tissue 
and of the epithelium through pressure of the extruded blood. In part 
there is also a fatty degeneration of the cells. 

As is known, the uterine mucous membrane possesses a remarkable 
power of regeneration, and there occurs, very soon after the cessation 
of menstruation, a restitution, so complete that only a few days later no 
remains of the previous changes are found. The detached epithelium is 
replaced by the remaining epithelial cells, and the blood poured out into 
the tissue, which has not reached the uterine cavity, is resorbed together 
with the interstitial tissue cells which have begun to degenerate. 

In discussing these normal menstrual changes we must consider an 
anomaly of menstruation which does not infrequently come to our 
notice, and which is of great diagnostic interest. It is that form of 
menstruation in which expulsion not only of fluid blood, but of entire 
layers of mucous membrane, or even the entire mucous lining of the 
uterus, occurs. Since the extrusion of such a membrane is accompanied 
by severe pain, this anomaly has been given the unfortunate name dys- 
menorrhea ruembranacea, thus classifying the anatomical product 
tiva which is found in recent works. This name is incorrect because 
does not agree with anatomical facts, is the name endometritis exfolia- 
tiva which is found in recent works. This name is incorrect because it 
this is not an inflammatory change. Indeed, the expulsion of such a 
membrane may occur in a uterine lining previously inflamed without this 
being the result of inflammation; for this anomaly occurs in mucous 



76 DECIDUA MENSTRUALIS. 

membranes which show no sign of inflammatory changes, just as in intra- 
or extrauterine pregnancy the expulsion of the decidua is no more to 
be considered the result of an inflammation than the above condition 
during menstruation. It is a process whose cause we do not yet know. 
"We must, therefore, be content with the existing fact, and it seems to 
me better to call the membrane expelled during menstruation 

Decidua Menstrualis. 

By this name the macroscopical appearance of this membrane is also de- 
scribed. 

We have seen that in ordinary menstruation, at times, in addition 
to the epithelia, individual shreds of the mucous membrane of the uterus 
are expelled. The menstrual decidua is then a cast of the entire in- 
terior of the uterus, which is thrown off complete or in pieces. What is 
the microscopical composition of such a decidua? 

In my opinion it would be false to establish a special type, and to 
make certain cells of the interstitial tissue or changes in the epithelia 
characteristic of such a decidua. One thing only may be said with 
certainty, and that is that this membrane consists of the superficial 
layers of the uterine mucous membrane. Accordingly, it will be found 
to contain the various elements of this lining, namely, glands, epithelium, 
inter glandular tissue, and vessels. Whether these elements reflect the 
picture which we have learned in viewing the normal mucous lining, or 
whether changes of an inflammatory kind are present, depends upon the 
state of the mucous membrane before the menstruation. I believe that 
in this way the various views of the different authors may easily be 
brought into harmony, for one considers this and the other that cell 
form of the interglandular tissue, and still another this or that change 
of the gland or superficial epithelium, to be characteristic of this condi- 
tion. The following figure (Fig. 27) represents the microscopical pic- 
ture of such an expelled menstrual decidua, Avhose mucous membrane 
must previously have been of normal character. The interstitial tissue 
shows the well-known oval cells which we have already learned to be 
the normal constituents of the interglandular .tissue. The abnormal 
element is the infiltration with small round cells ; but this is natural, 
since we are dealing with a menstruating mucous membrane into which 
red and white blood cells have entered from the vessels. That these round 
cells lying isolated between the cells of the interstitial tissue have really 
come from the vessels is evidenced by the marked grouping of such 
cells about the vessels themselves. A third essential constituent is found 
in the section through a gland at d. This does not show the normal 
round form, but is somewhat dilated, which must not be considered 
pathological, since the uterine glands possess, as a rule, no defined 
mathematical form, but have sometimes a narrower, sometimes a wider 
lumen. The epithelia of the glands are not much changed from the 



DECIDUA MENSTRUALIS. 



77 



normal, even though they are closer together than usual. A specially 
characteristic change, such as a decidua shows in pregnancy, is, however, 
not present. Inside, the gland shows an indistinct mass which seems 
to be a clot (mucus, blood). This corresponds to the ordinary occurrence 
in menstruation. That the capillaries found in such casts are turgid with 
blood deserves no special consideration. 




Figure 27. — Mensteual Decidua. 
a, section through vessels surrounded by groups of round cells ; 1), interglandular tissue 
consisting of normal cells with scattered round cells ; d, section of a gland somewhat 
dilated — its epithelia are somewhat smaller than normal. 



In the above section there are, therefore, all the constituents of the 
mucous membrane in an almost normal condition. If an inflammation 
with productive changes had previously existed, then all the cells could 
take on those forms which we shall later recognize in discussing inflam- 
matory processes. They can develop into large decidua-like cells or 
show regressive changes. At any rate, it would be false to say that 
the large cells of the interstitial tissue resembling those occurring during 
pregnancy are characteristic of a decidua shed during menstruation; 



78 ENDOMETRIUM IN PREGNANCY. 

just as false as if an accidental increase of connective tissue were con- 
sidered typical. If, on the other hand, productive changes in the gland 
epithelium had been present — for instance, proliferation which lei to 
the formation of several layers — the same condition would be found in 
the mucous lining expelled during menstruation. 

Since the shedding of such a menstrual decidua is often accompanied 
by profuse bleeding, the question for the medical man is, whether or not 
an abortion is in progress — a question whose decision might be of great 
importance in a court of law. 

Is it possible, with the aid of a microscope, to decide whether such an 
expelled uterine cast or piece of tissue is related to a pregnancy or not? 

For this purpose we must consider those changes to which the uterine 
lining is subjected during pregnancy. As pregnane^" is a physiological 
function of the uterus, the discussion of the changes occurring therein 
belongs naturally to the normal anatomy of the uterine mucous mem- 
brane, just as is the case with menstruation. Of course, the change in 
the uterine lining in pregnancy is so decided — certain elements which we 
have learned above disappear entirely and others are newly formed, 
while the form of still other elements is changed— that it is always diffi- 
cult to explain to the beginner that all these changes lie within physi- 
ological limits. At any rate, the microscopic pictures bear such a re- 
semblance to pathological processes, at least in small pieces removed for 
diagnostic purposes, that even the practised microscopist may diagnose 
from such a specimen a malignant neoplasm, may extirpate the uterus 
and subsequently find a normal pregnancy without the least evidence of 
a pathological process. 

In the present discussion we are concerned exclusively with practical 
and weighty questions, and not with special anatomical examinations. 
Diagnostic doubts exist only in the early months of pregnancy, when 
the enlargement of the uterus is still slight. If, for instance, as often 
occurs, the fetus is expelled unnoticed, and if subsequent bleedings of 
an irregular type result, which bleedings in a short time weaken the 
patient, or if we are dealing with an expelled piece such as occurs in 
extrauterine pregnancy, then these evidences are often of such a char- 
acter that a suspicion of the existence of a neoplasm may seem justifiable. 
The history, which should be an important factor in diagnosticatin.e a 
pregnancy, cannot be considered decisive in this case, for it is kno^vn 
that all possible deviations from the normal occur. Naturally, in doubt- 
ful cases, it would be of great value if microscopical examination could 
decide with certainty whether we are concerned with a pregnancy or 
a neoplasm. Frequently it depends upon this diagnosis whether an 
operation, and what sort of an operation, should be done. 

iy) The Endometrium during tlie First Months of Intrauterine Pregnancy. 

On the occurrence of pregnancy a very peculiar stimulation is ex- 



ENDOMETRIUM IN PREGNANCY. 79 

erted upon the uterine miicons membrane, whose product results iu a 
mucous lining thickened to ten or more times its original depth. This 
thickening is caused by the growth of the various elements forming the 
mucous membrane, which are affected in varying ways by this event. 

At the beginning of pregnancy, and hand in hand with the increase 
in thickness of the mucous membrane, an enlargement of the glands takes 
place. This is irregular in that the parts situated near the outlet are 
stretched and considerably widened, while the deeper parts of the glands, 
as far as the muscle layer, become very tortuous. In microscopical sec- 
tions this varying increase is such that the inner parts of a section show 
less numerous glands, while those portions situated in the external layers 
of the mucous membrane and near the muscle show so mam gland 
lumina that the intergiandular tissue steps into the background. This in- 
itiates a division into two layers, which later becomes still more marked; 
for the more the intergiandular tissue disappears in the external layer, 
^here there remains only a honeycombed tissue consisting almost 
entirely of glands, the more does this interstitial tissue develop 
in the inner layer, so that here the very opposite occurs, namely, a dis- 
appearance of the glands as a result of a complete overgrow+l'. of the 
interstitial tissue. In this way there occurs a division of the mucous 
membrane into two parts, which, in accordance mth the appearance 
and consistence of the tissue, is called the '^ compact" or "cell layer" 
and the "spongy" or "glandular layer." The "cell layer" is that 
which is thrown off in the expulsion of the ovum, while the "gland 
layer" remains in the uterus and is intended to furnish the regenerating 
mucous membrane with epithelium for the glands and for the surface 
lining. 

If these elements are viewed singly it appears that the epithelium 
lining the glands loses its form entirely (Fig. 28, a). In place of the 
delicate high cylindrical cells there are formed flat cubical s'.ructuies 
which become flatter the longer pregnancy continues, so that they are 
hroader than long, contain little protoplasm, and furnish cells almost 
entirely filled out by the nucleus. The resemblance to cylindrical cells 
almost disappears, but their resemblance to squamous epithelium is only 
an external appearance, as their origin is, as we have just seen, entirely 
different. 

If we observe the various sections of glands in Fig. 28 it will be seen 
that these have quite a different form from that found in the normal 
-endometrium. In comparison with this, the glands are here dilated and 
of irregular form. Nothing is seen of the almost circular section, in 
which the gland lumen represents only a small space surrounded by 
high epithelium. What, however, is striking in this figure is the triangu- 
lar form in this case, although pregnancy had existed only about seven 
weeks. This triangular shape becomes continually more marked, and the 



80 



DECIDUA OF PREGNANCY. 



gland remnants, which at the end of pregnancy lie close to the muscularis, 
have, as a rule, only this form. 

I have gone into these changes in the glands extensively because 
great importance has been attached to them in test curettings in making 
the diagnosis of pregnancy. It has been said that in such pieces, or in 
pieces spontaneously expelled, the flattening of the cylindrical epithe- 




FiGURE 28. — Decidua in Ikteauterine Peegnakcy (abortion) at the Second Month 

(curetting). 

a, section of a gland with flattened epithelia ; 6, interstitial tissue consisting of the 
so-called decidua cells, between which at certain points irregularly scattered round cells 
are seen ; c^ section of a vessel — in the wall are endothelia. 



iium is a characteristic of pregnancy. Even though it must be granted 
that this change in the epithelium is very striking and very marked, and 
that the skilled microscopist, who continually has the opportunity of 
making such examinations, attaches without doubt, in judging such a 
specimen, great weight to the flattening, the diagnosis of pregnancy 
should never be made from that fact alone. Such uncertain statements 



DECIDUA CELLS. 81 

should not be taught the beginner. In this way disaster may easily re- 
sult when we consider the importance of such diagnosis. Besides, we 
shall discuss further on the possibility of making the diagnosis "preg- 
nancy" from the decidua cells alone. 

It remains for me to discuss in a few words the change in the surface 
epithelium. This is subjected more than the glands and their epithelium 
to the pressure of the growing ovum. In consequence it becomes flat- 
tened earlier than the latter, and forms, after a short time, only an 
endothelial-like covering, which in the second half of pregnancy dis- 
appears, so that at that time the decidua comes into direct contact with 
the membranes, with which, as is known, the "cell layer" unites, being 
then thrown off with the ovum in toto at the end of pregnancy. 

The same changes as those on the surface occur in the epithelium 
which lines the outlet of the glands, and in the glands in their entire 
course. Here, likewise, the epithelial cells are changed into a very fine 
endothelial-like layer, which later on disappears, so that it is no longer 
possible to say from the appearance of such a canal whether or not we 
are dealing with a gland. This can only be proved by following its 
course. 

We are now to consider the interstitial tissue. This is still more 
changed than the glands and the epithelium. The cells of the interstitial 
tissue (Fig. 28, &) enlarge at the beginning of pregnancy, and increase 
in size the more pregnancy advances, so that at its end they are five to 
six times as large as those in the non-pregnant endometrium. This in- 
crease in size in the individual cells concerns the protoplasm more than 
the nucleus; for, while in the normal endometrium the nucleus forms the 
main portion of the entire cell, and the protoplasm is relatively small, 
the contrary is the case with the cells of the pregnant endometrium. The 
nucleus retains almost its original size, while the cell body continually 
grows, and in this way there results in these so-called "decidua" cells 
a certain resemblance to squamous epithelium. This resemblance be- 
comes still greater through the continuous pressure exerted upon the 
tissue, and the cells lose their original oval form and become mutually 
flattened. In addition, under the continued growth of th'e cells, the 
tender connective-tissue network between them disappears, so that the 
large decidua cells lie almost in direct contact Avith each other, being 
separated only by small spaces in which here and there small round cells 
are visible. The whole presents a very uniform and regular picture, so 
sharply characterized that we would naturally believe any doubt with 
regard to the diagnosis of such a specimen excluded. When we are deal- 
ing with such normal conditions we are, as a rule, in a position to make 
a positive diagnosis. 

In our practical examinations we are usually dealing, not with nor- 
mal, but with pathological conditions; and although they have been de- 
scribed above, they are not present with the same clearness, but are 
6 



82 ENDOMETRIUM IN EXTRAUTERINE PREGNANCY. 

usually combined with otlier pathological changes, which permit of 
different possibilities in the way of diagnosis. The discussion of this 
C[uestion will be our task when describing the individual affections. 

The vessels of the inter glandular tissue take part decidedly in the 
changes of the other elements. Veins and arteries, so far as they run in 
the mucous membrane, lose their muscle wall during pregnancy, and 
present only simple endothelial channels Avhich are not so delicate and 
thin as the capillaries of the normal endometrium, but take part in the 
general growth and form large spaces filled with blood. At the location 
of the placenta, the decidua hasalis, or decidua serotina, these endothelial 
tubes open on the surface and send their endothelium upon it, since the 
epithelium of the former disappears; and they also send their endothe- 
lium over the chorionic villi ( ? ) , so that the spaces between the villi are 
walled oft" in their entire circumference from the fetal structures. They 
form, therefore, nothing but dilated Mood sinuses originating from the 
maternal decidua. 

These relations, the recognition of w^hich has caused so many dis- 
putes, are, according to recent investigations, no longer to be doubted, 
and are confined only to the first weeks of pregnancy. Later the epi- or, 
better, the endothelium disappears here as upon the surface, and the 
maternal circulation comes into direct contact with the fetal elements. 

It is to be hoped that these remarks suffice to show the changes of 
the endometrium during the early period of normal pregnancy. Even 
though an extrauterine pregnancy is not normal in the obstetrical sense, 
the changes which it causes in the mucous lining of the uterus cannot 
be considered, pathological. They are nothing else than the changes 
(Of pregnancy— L e., only a variation of the endometrium, which is sub- 
ject, as w^e have seen, to so many other variations in its normal structure. 

(^\ The Endometrium in Extrauterine Pregnancy. 

All examiners are united in the opinion that in an extrauterine preg- 
nancy a decidua is formed in the uterus, i.e., a membrane which is later 
thrown off. Concerning the structure of this decidua, on the contrary, 
opinions are at variance, at least with regard to the membrane spon- 
taneously expelled from the uterus— an event which does not always 
but which does frequently occur in extrauterine pregnancy. This 
spontaneous shedding is usuall3^ a sign that the fetus is dead. If we can 
determine by a microscopical examination that this decidua originates 
from an extrauterine gestation, it is without doubt of great value in 
determining the treatment. The changes which take place in the forma- 
tion of a uterine decidua connected with an extrauterine pregnancy are 
the following : 

The endometrium shows changes which are distinguished in two 
ways from those in intrauterine pregnancy. First, the stimulus is de- 
cidedly less when the ovum is not in the uterus; therefore the increased 



DECIDUA IN EXTRAUTERINE PREGNANCY, 83 

conditions in the way of growth are not so decided as in normal preg- 
nancy. Second, the formation of the decidua is comx^leted at two to two 
and one-half months. Up to that time the entire uterus takes part in the 
growth, so that in palpation, if the entire ovum is not felt as an isolated 
tumor, a difference as regards the size of the uterus does not exist be- 
tween an intra- and an extrauterine pregnancy. After this time, if this 
condition be interrupted in some way or other, the uterus undergoes 
involution ; if, on the other hand, the pregnancy continues (the ovum 
can develop to full term outside of the uterus ) , then in spite of this 
fact the growth of the uterus ceases. As a rule, the uterine decidua 
undergoes involution in the latter months of extrauterine pregnancy. 
Under these general suppositions the change in the endometrium occurs 
in such a way that in the first three weeks almost the same conditions 
are to be found as in a normal pregnancy. 

The cells of the interstitial tissue enlarge, but even in the third month 
do not attain the size seen in these cells at the end of the first month 
of an intrauterine pregnancy. The increase concerns mainly the cell 
body, while the nucleus remains about the same size as before. A further 
difference, as compared with normal pregnancy, is that the cells do not 
become mutually flattened, but retain almost their original oval form. 
This condition is to be explained by the different conditions of pressure 
which exist. In the second month — and here especially are the opinions 
of different authors at variance — the growth of the cells of the inter- 
glandular tissue is increased to such an extent that, as a result of my 
examinations, there occurs the formation of an exclusive ' ' cell layer ' ' as 
the inner lining of the mucous membrane. The gland openings, as in 
intrauterine pregnancy, are overgrown, and only the deeper part of the 
glands, the fundus, remains clothed with epithelium. There is formed 
then a continuous "cell layer." This alone, in case of spontaneous ex- 
pulsion of the decidua, is thrown out of the uterus, ivhile the ^' gland 
layer" remains behind. The epithelial cells of the glands are distinctly 
flattened. In the increase in thickness of the mucous membrane the 
glands become elongated near their openings, while toward the muscle 
layer they are tortuous. The superficial epithelium becomes flat, so that 
at completion of the decidua formation only a delicate endothelial-like 
covering is present. The following picture gives a microscopical section 
through such a membrane (Fig. 29). 

I have had repeated opportunity to substantiate this condition in the 
case of membranes spontaneously expelled, and I must therefore con- 
sider it as usual. If in the early stages of an extrauterine gestation 
decidua is expelled, which is unusual, sections of glands may be found. 
The epithelial cells have the broad cubical shape characteristic of preg- 
nancy. A positive diagnosis cannot be made from the examination of 
the microscopical specimen alone. 

The depression which is seen in Fig. 29 is to be explained by the fact 



84 



DEGIDUA IN EXTRAUTERINE PREGNANCY. 



that the inner surface of such a cast of the uterine cavity is not smooth, 
but shows a very remarkable grooving. This has been remarked by 
various observers, and by some has been considered to be connected with 
the division of vessels. At the height of those fields formed by grooves 
a star-shaped, divided vessel is supposed to be found. The vessels change 
in the same way as in normal pregnancy. The ''cell layer" is filled 
with a network of fine capillaries much wider than normal. The nearer 
we approach the deeper layers from the surface, the larger become these 
fine vessels, so that they are there four to five times as large. They run 
partly parallel to the surface, partly obliquely to it, and lie at times so 
close beneath it that no cell layer can be distinguished over them: While 
in the deeper layers their course is a twisted one, near the surface they 
are straight. Extra branches are not given off by the vessels. In my 
specimen I could see the vessels everywhere lined with a distinct en- 




FiGUEE 29. — Spontaneously Expelled Uteeine Decidua in a Tubal Gestation (two 

and one-half monilis). 

St., stroma consisting of enlarged cells; Ep., surface epithelium stretched to an en- 
dothelial-like membrane — at a it is loosened from the underlying tissue as a result of the 
cutting. 



dothelium. Whether I was dealing with capillaries cannot be stated 
positively, for the arteries as well as the veins lose their muscular wall in 
the change from endometrium into decidua. 

This is not the place to enter more closely into the very difficult 
relations; I believe I have discussed sufficiently what is important for 
practice. 

That these relations are of great importance in practical diagnosis 
is shown by the fact that the microscopist is often asked w^hether a 
piece expelled from the uterus is a menstrual anomaly, or whether it is 
related to an abortion or to an extrauterine pregnancy. The decision 
of this question is of importance in many ways. Upon such a decision 
may depend the acquittal or condemnation of one accused of artificial 
abortion. Upon it depends likewise the therapeutic procedure if. the 



DIFFERENTIAL DIAGNOSIS. 85 

diagnosis reads ' ' extrauterine gestation. ' ' Even though these conditions 
have been minutely considered in the previous discussion, a still clearer 
idea may be obtained if we briefly view these three conditions from the 
standpoint of differential diagnosis. 

(£) iJilferential Diagnosis betw^een Menstrvial Decidiia, Uterine Decidiia in Intrauterine 
Pregnancy (Abortion), and in Extrauterine Gestation. 

In discussing the changes of pregnancy, stress has been laid upon the 
fact that the cells of the interstitial tissue change into the so-called 
' ' decidua cells. ' ' It must be mentioned, at the beginning of the discus- 
sion upon differential diagnosis, that the decidua cells have, as we may 
say, no specific signification. It is impossible to diagnose a pregnancy 
from the presence of these large cells alone, for, aside from pregnancy, 
they may result from any irritation or stimulus ivhich causes increa'scd 
groivth: The cells of the interstitial tissue are, like the entire mucours 
membrane, subject to much change in their form, but return to their 
normal appearance, as a rule, as a result of the power of regeneration 
inherent in the mucous membrane of the uterus. The same is true of 
the epithelial cells of the glands. They take on, so long as pregnancy 
exists, a flattened changed form as the result of pressure ; but so soon as 
pregnancy is interrupted and abortion takes place it does not take long 
before their previous form is regained. Usually we are dealing with a 
bleeding which has existed for some time when we are called upon 
to make a diagnosis of pregnancy from such uterine sheddings, and the 
.epithelium has meanwhile had sufficient time to regenerate. Even 
though this were not the case, the flattened or cubical epithelial cells are 
quite as uncertain a sign of pregnancy as are the decidua cells. I have 
frequently found glands lined with such low epithelium in cases of 
uterine myoma. It would be sad if we wished to make the difference 
of a micron, more or less, in the size of an epithelial cell an important 
point in diagnosis. 

The following drawing (Fig. 30) serves as an illustration of what 
has just been said. It is taken from a specimen expelled from the uterus 
of a patient who had bled for three weeks. Menstruation was previously 
always regular ; only at the last period the bleeding did not cease as usual 
after six days, but continued, so that she was very anemic when taken 
into the clinic. The patient appeared so cachectic that it occurred to me, 
in consideration of the history, that either a benign or malignant neo- 
plasm was present. Not the least support for the idea of an interrupted 
gestation was present, for the patient denied the expulsion of an ovum 
or of pieces of tissue. 

If we observe the specimen we find the interstitial tissue changed 
into so-called "decidua cells"; to be sure, not of the same size at all 
points, but only at c as large as we have described and illustrated in 
intrauterine pregnancy (Fig. 28, h). Here there is also a distinct flat- 
tening of the cells. At h, on the contrary, the cells resemble ordinary 



86 



UTERINE DECIDUA ( ABORTION). 



interstitial cells more than decidna cells. In the neighboring area also 
the other cells are not so large as those at c, and under the space d, filled 
T\dth blood, may be seen distinct spindle cells. To the right of this blood 
space filled ^vith red blood cells there are at a and around a several 
sections through dilated capillaries tnrgid with blood. In addition there 
is a section through the gland e, whose epithelium shoAvs no flattening and 




which is also filled with blood. I should not have considered it justifiable 
to make the positive diagnosis of pregnancy from this section alone, 
for it might just as well have been a menstrual decidua. The size 
of the connective-tissue cells might easily be due to a productive in- 
flammation existing before the expulsion of the membrane. In spite 
of this the diagnosis of pregnancy was positively made, but was founded 
on the examination of further sections. These showed, in addition to 



CHORIONIC VILLI. 



87 



the tissue wMcli greatly resembled a uterine decidua, other tissues of 
fetal origin, namely, chorionic villi. 

From this we come to the conclusion thait a positive diagnosis of abor- 
tion can never he made from the uterine decidua alone, hut only through 
the presence of tissue of fetal origin, i.e., chorionic villi. 

Since I have frequently observed during my lectures that very few 
know the appearance of chorionic villi, I have given in Fig. 31 an illus- 
tration, which comes from the same specimen as the previous dramng. 
The chorionic villi are like trees with branches and twigs, and are sup- 
posed to furnish the connection between the ovum and the uterine de- 
cidua. They consist of a stroma (c) and an epithelial covering (h). 




















'■^■■'k^,- 



mi^^^i^mms^s^p -^ 



V ^- >^-?! r.; <; ?f^**-fj'^-f^- ' ■ -^t^:^^^^^^^'f^''«Z'ii O'- 






_-;J.- M ■-"- 



c£: 



Figure 31. — Chorionic Villi (strongly magnified). 

a, blood coagulum in the intervillous space ; 1), epithelium (double layer of nuclei) ; 
c, embryonal connective tissue of the villi (the largest villi are cut longitudinally and 
obliquely) ; cl, section through the tip of a villus ; e, transverse section through a villus. 



The stroma is formed of embryonal connective tissue, i.e., young cells 
or nuclei which lie irregularly in a colloid substance in which connective- 
tissue fibres are formed in the later months. The epithelial covering 
varies according to the age of the ovum. At the beginning of the sec- 
ond month three layers have been distinguished as clothing the villi, 
two of which layers are cubical epithelium (Fig. 31, h), the other being 
a very thin layer of endothelium, which is marked off from the blood 
in the spaces between the villi as a very thin membrane. The latter 
represents the endothelium of the dilated maternal blood vessels. In 
these epithelial cells are seen nuclei only, which are suspended in a 
homogeneous substance; cell borders can be distinguished only at an 



88 



CHORIONIC VILLI. 



early period (syncytium). In the later months there is usually only 
one layer of epithelium present, which eventually also disappears. 

In the sections made through such pieces coming from an abortion 
we do not always get villi without other tissues, as in Fig. 31, but trans- 
verse sections through villi surrounded by the decidua cells described 
above; for one form of the villi, the so-called "adherent villi," are in 
direct connection with the decidua, in which they are planted firmly, 
furnishing the first union between the maternal and fetal organisms. 
In such specimens the villi are sharply outlined from the cells of the 




Figure 31a. — Section through a Blood Clot removed from a Uterus after Arortion 

(slightly magnified) . 
Transverse and longitudinal sections of villi of various sizes ; below and to ttie right 
an epithelial elongation ; the epithelial covering of the larger villus in the middle mostly 
lited off by blood. (After Orth.) 

interstitial tissue, so that, once observed, doubt concerning their character 
can never arise. 

It is, therefore, always possible, if chorionic villi are present, to recog- 
nize a piece expelled from the uterus as connected with a pregnancy, 
and in this way to distinguish it from the other two forms of decidua. 

What is, then, the difference between the decidua cast off during 
menstruation and one cast off in an extrauterine pregnancy? Accord- 
ing to my observations, which have been confirmed, a spontaneous expul- 
sion occurs only when the "cell layer" is entirely formed, for only 
this is thrown off (in normal pregnancy with the ovum) here without 
the ovum. The fundi of the glands remain behind in the uterus, and for 
that reason such a decidua consists of enlarged decidua-like cells. These 



CHORIONIC VILLI 89 

are covered with an endothelial-like layer which represents the changed 
surface epithelinm. Glands are not present. 

In a menstrnal decidua, on the other hand, the surface epithelium is 
present in part, and the cells are of a cylindrical form as in the normal 
endometrium. Although, as a result of mechanical injury, no surface 
epithelium may be present, glands are still always to be found, and 
their epithelium as a rule appears quite normal. The cells of the in- 
terstitial tissue show in most cases no other changes than those caused 
by the pressure of the poured-out blood. Therefore no great weight 
can be attached to this condition, for the cells may be changed by pre- 
vious affections of the endometrium, so that all stages, from normal 
cells to giant and decidua-like cells, are found. Therefore the char- 
acteristic difference consists in the presence of glands and of unchanged 
surface epithelium, in the one case, and in the change of this epithelimn 
to an endothelial-like cover, and the ahsence of any formation which may 
he considered a gland, in the other case. 

It is evident that it would be wrong to curette the uterus for the 
purpose of making a microscopical examination in suspected extrauter- 
ine pregnancy, for in this event the deeper-lying layers Avould be also 
removed. In that way one of the important criteria for the diagnosis 
would be lost. From a clinical standpoint, also, such a curettage is con- 
traindicated, since many cases are kno^^Ti in which after this procedure 
immediate rupture of the ovum resulted with fatal internal hemorrhage. 

2. PATHOLOGICAL ANATOMY, 

A. General Remarks. 

The pathological anatomy of the endometrium, if discussed in a sys- 
tematic manner, would take us too far from the practical purposes which 
we are following. We should lose ourselves in details which would re- 
move us from the essential questions concerned in the subsequent por- 
tion of this book. It must, therefore, not be viewed as peculiar if we 
do not speak of the usual division into acute and chronic inflammations, 
since we are only concerned with giving those general evidences ob- 
served in the curetted particles which lead to the practical and weighty 
decision as to whether we are dealing with an inflammatory condition 
or a neoplasm, and whether this neoplasm is anatomically benign or 
malignant. 

Test curetting of the uterine lining has without doubt furthered 
early diagnosis. In this lies, in all branches of medicine, an important 
factor in deciding therapy. Where the clinical symptoms give us no 
positive diagnosis, at times the removal of a small piece permits us to 
say, for instance, that we are dealing with a carcinoma, provided that 
we are fortunate enough to have found the affected area with the 



90 ENDOMETRIUM — PATHOLOGICAL ANATOMY. 

curette. A negative result in such examinations is never a positive proof. 
Here, again, the deficiency of even this method may be observed, for a 
method can accomplish no more than is within the limit of possibility. 
If a small piece has been removed by the cnrette, we can only say that in 
this piece such and such changes have been found; whether other con- 
ditions exist in the uterus cannot be judged from such a specimen. It 
would be false to state, after examining a curetted piece in a doubtful 
affection of the uterine mucosa, that all doubt as to the nature of the 
affection has been removed. This may he the case if the evidences are 
characteristic enough to make a diagnosis positive; but it is not neces- 
sarily so. 

Another point is this : in making a test excision from the vaginal 
portion we see at least the affected area from which a piece is taken. 
This is not the case in curetting, and, as a rule, the uterine mucous 
lining is removed blindly, healthy and affected areas without distinction. 
In the early stages, as a rule, only isolated areas of the mucous lining 
become affected, especially in the case of a malignant neoplasm. This 
appears at first as an isolated tumor, at times of microscopical size. It 
needs considerable luck to find, among the numerous healthy or only 
secondarily changed particles just removed, the area of importance to us ; 
or else innumerable sections must be made and examined before saying 
that in the curetted particles positively nothing carcinomatous is present. 

Since in curetting the eye is of no value, another method which 
will supply this deficiency in doubtful cases is certainly of importance. 
This means we possess in the process of examination of the uterine cavity 
with the finger after its dilatation. Unfortunately, this method is used 
too rarely. 

When the uterus has been dilated by one method or another, so that 
its cavity can be palpated up to the fundus, the examining finger detects 
the isolated affected areas either through their hardness or softness, or 
other variations. At times the finger can directly loosen the brittle 
masses. If this be not possible we know at least at what point we should 
observe especial care in doing a test curettage. Even in this way, 
naturally, we cannot always make an exact diagnosis, for there are cer- 
tain limits beyond which our microscopical knowledge does not carry us. 

Nevertheless, even though a microscopical examination has furnished 
us with no positive evidences of one or another affection, it is still an 
important aid in many doubtful cases when used in conjunction with 
the clinical results. If, for instance, the patient is a woman who has 
long passed the climacterium, we know that the character of the en- 
dometrium is different from that after puberty. The glands have partly 
disappeared and the interglandular tissue shoAVS an increase of the 
elements situated between the cells ; much fibrous connective tissue is de- 
veloped, and the cells, which formerly were so prominent, disappear. If, 
in case of sudden bleeding which is not controlled by the usual means, 



ENDOMETRIUM — PATHOLOGICAL ANATOMY. 91 

a test curetting be done and a rich development of glands be ob- 
served microscopically, this fact alone, even though it does not justify 
immediate radical treatment, demands minute observation and further 
close study of the case. In other words, the microscopical examination 
is an exceedingly important aid in supporting a clinical diagnosis, even 
though it does not always furnish an absolutely certain result. 

Another point should be mentioned. Are we able, from certain points 
observed in curetted particles, to say with certainty that in the ex- 
amined specimen no malignant neoplasm exists, in spite of the fact 
that in all probability such a condition is present in the mucous mem- 
brane? 

This question is justified by the f oUomng statement : It has been 
settled, bv examination of manv an entire uterus affected mth carcinoma 
and obtained by operation or by autopsy, that very often in the cir- 
cumference of a carcinoma striking hyperplastic changes in the epithelia 
of the neighboring glands occur. The originally simple epithelial layers 
increase so that the gland wall is covered with two or more stratified 
layers. Through pressure these epithelial cells easily lose their cylindri- 
cal form and become fiat. In oblique sections such pictures result that 
the gland wall seems to be lined mth a stratified layer of squamous epi- 
thelium. This led certain examiners to believe that such an increase of 
the cylindrical cells represented the beginning of a carcinoma. If such 
hyperplastic formations are seen in the glands of a curetted specimen 
we must conclude that this is not a real carcinoma, according to the 
usual anatomical claims, but that it may easily represent a beginning 
stage. Since such pictures are often found in the circumference of 
a carcinoma, there may be carcinoma present in the supposed case. This 
conclusion I do not consider justifiable, for the simple reason that such 
pictures are by no means characteristic, but, as we have seen before, 
may occur in entirely henign changes. I would therefore ad\dse the 
beginner never to let himself be influenced to make a diagnosis which 
does not accord with the facts, but which is only a possibility. 

As microscopists we should only judge the complete anatomical speci- 
men before us, and make a diagnosis according to positive observations. 
So long as we know no characteristic etiological e\ddences the anatomist 
and the clinician frequently come into conflict. It then must be left 
to the experience of the clinician whether, in spite of the negative micro- 
scopical condition, he is to operate or not. We dare not, however, for 
that reason recede one step from the real basis. 

After these preliminaries we are to discuss the affections of the en- 
dometrium as we generally find them in curetted particles. As a rule, 
a curettage of the uterus for microscopical purposes is usually done be- 
cause of long-continued bleedings, i.e., chronic cases. Having already 
discussed the conditions present in abortion, the following chapters deal 
only with infiammatory and hyperplastic changes and ^Yii'h malignant 
neoplasms. 



92 INTERSTITIAL ENDOMETRITIS. 

B. Inflammations. 

It is not always easy, and is sometimes impossible, to define the limit 
between inflammations and neoplasms of the endometrium. As a result 
of the various processes which occur the different conditions often over- 
lap ; or, as a result of the circulatory changes caused by inflammations, 
certain tissue forms proliferate, since the endometrium reacts ener- 
getically to every stimulus. In spite of this fact we may distinguish two 
forms of inflammation of the endometrium which, in their final stages at 
least, show special and quite different characteristics : interstitial en- 
dometritis (atrophicans) and hypertrophic endometritis (fungosa). 

Those conditions which no longer show evidences of inflammation 
and are probably the result of an inflammatory irritation, give in the 
microscopical specimen the impression of newly formed tissues, and I 
therefore prefer to class them with the hyperplasias of the endometrium. 
This may affect the glands and the interstitial tissue at the same time. 
We then speak of a diffuse and a circumscrihed (polyposa) hyperplasia 
of the whole endometrium, depending upon whether the entire mucous 
membrane or only part of it is affected. 

If, on the contrary, we are dealing with an increase of the glands 
alone, which in excessive cases may lead to complete disappearance 
of the interglandular tissue, this condition (depending upon whether 
the entire mucous membrane or only a part is affected) is called 
diffuse and circumscrihed (polypoid) hyperplasia of the glands of the 
endometrium. Under these names are included all growths of the en- 
dometrium which are inflammatory and clinically as well as anatomically 
benign. For the malignant and destructive neoplasms are reserved the 
generally accepted and recognized names, such as adenoma, carcinoma, 
sarcoma, and the mixed forms. Such a clear division between benign and 
malignant changes of the endometrium would probably lead to a pre- 
vention of the many disadvantages which, in part at least, are caused 
by a confusion in the gynecological-anatomical nomenclature. 

i<X.) Interstitial Endometritis. 

As is indicated by the name, the important changes take place 
in the interstitial tissue. All the changes which are usually char- 
acteristic of inflammation are likewise found in inflammations of the 
uterine mucous membrane. The interstitial tissue, if the affection has 
not existed long, is infiltrated with small cells in proportion to the 
severity of the irritation which causes the inflammation. The round cells 
replace completely the original cells of the interstitial tissue in certain 
areas, so that the gland sections are absolutely surrounded by small- 
celled infiltration. In gonorrheal endometritis gonococci are found in 
the interstitial tissue and in the glands. The glands at first are only 
slightly changed; at most the epithelial cells in certain areas have pro- 
liferated as a result of the increased blood supply, and line the gland 
wall in several layers. 



INTERSTITIAL ENDOMETRITIS. 93 

This is a condition found in nearly all inflammatory and hyperplastic 
formations of the endometrium, and has no special significance. 

The following figure (Fig. 32) shows this stage of the affection, from 
which, after existing for a long time, other changes may result. These 
finally cause the entire mucous membrane to be replaced by a layer of 
fibrous connective tissue. Therefore the same condition results here 
through inflammation which we have previously learned to be a normal 
condition after the menopause. 

Before this end-stage is reached the endometrium goes through the 
following changes : The small round cells gradually become many times 
their former size. The longer the process continues, and the more nutri- 
tion these ce'lls obtain from the newly formed vessels (which occurs in 
all inflammations), the larger these cells become, so that, with their large 




FiGUEE 32. — Interstitial Endometritis. 

a, sections of capillai'ies : l», space resulting from contraction of tlie gland wall in 
alcohol : c, interstitial tissue everywliere replaced by a small-celled infiltration. The 
epithelial cells of the glands are at points arranged in many layers. 

nuclei and their plentiful protoplasm, they resemble epithelioid or de- 
cidua cells. This latter resemblance has led anatomists to believe that 
this is a specific process of the endometrium. This is not so, for Avhoever 
takes the trouble to read in Cohnheim's text book, vol. i., page 366, the 
changes occurring in a productive inflammation with incomplete regener- 
ation, will find that such a formation of epitlielioid cells is usual in such 
an inflammation. Just as the formation of these cells occiirs, so there 
may arise various transition forms, from the srnall round ce'l.s up to giant 
cells with many nuclei, to spindle-shaped cells, club-shaped cells, and cells 
with processes. 

In examining the small curetted particles we find that the process 
does not attack all parts of the mucous membrane alike, nor does it 
run the same course in all parts, and we therefore observe the products 



94 HYPERTROPHIC ENDOMETRITIS. 

of inflammation in its various stages. While, in one bit which has been 
examined, such areas with large and spindle-shaped cells may be seen, 
in other pieces small round cells with regressive changes, fatty degenera- 
tion, and a destruction of cells may be observed. 

The further changes go on in the endometrium in the same way as 
in other organs, and there results, as Cohnheim says, "the further de- 
velopment of the large epithelioid cells. The early round epithelioid cells 
send out processes, and become fusiform and stellate. The processes 
grow and undergo further metamorphosis, the characteristic of which 
is the splitting into fibres and fibrils. Since the fibres of various cells 
lie close together, there result bundles of fibrils to which, as a rule, 
several cells belong. The protoplasmic remnants which result in .this 
formation of fibrils remain and form cells w^hich lie between these 
bundles. The frame or supporting framework in which this develop- 
ment takes place is formed by the network of new vessels which have 
originated in the anastomosing vessel arches. What, lioivever, lias re- 
sulted from this process is, when summed up, nothing more than genuine 
vascular connective tissue.' ' Whether this view is correct or not can be 
proven only by further examination. I have simply quoted it to show 
that epithelioid cells are not formed as a specific product in the uterus 
alone. The only thing which must still be mentioned is the condition 
of the glands. These are pressed and become atrophic as a result of the 
continued increase of the interstitial tissue. The glands disappear from 
the superficial layer, which is replaced by connective tissue, and there 
remain only isolated atrophic gland fundi in the deeper layers of the 
mucous membrane. These disappear likewise when the process has 
terminated, so that the uterine lining is no longer a mucous membrane 
b)ut a layer of fibrous connective tissue (atrophic endometritis). 

{/3) Hypertroi^liic Endometritis (Fungosa). 

A¥hile in an interstitial inflammation the interstitial tissue plays an 
active role, in the hypertrophic form all parts of the mucous membrane 
are affected. A decided thickening of the mucous membrane may re- 
sult if this affection be present for a long time. The membrane grows 
either equally in all areas or, as is more frequent, only certain regions 
-are affected. These overgrow the remainder of the mucous membrane 
^nd rest upon it like a fungus. 

The name introduced by Olshausen distinguishes the process very 
well, for the microscopical changes vary so much in the different stages 
and according to the degree of inflammation that it is impossible to 
select for it a uniform title. The difference between it and the pre- 
viously named inflammation consists in the fact that here no disap- 
pearance of tissue occurs as a terminal process, but, on the contrary, a 
growth of the same takes place. Just as the interstitial tissue is in- 
creased, so also is there a growth of the glands. They increase in number 
i\nd in size, and in some places the cylindrical epithelium is found strati- 



HYPERTROPHIC ENDOMETRITIS. 



95 



fied. Through the coexisting growth of the interstitial tissue the form 
of the glands is changed ; the interstitial tissue forms projections toward 
the gland wall whereby the lumen of the glands is filled with numerous 
folds. In other places the interstitial tissue retracts, drawing the gland 
wall with it and causing dilatation of the glands. In the interstitial tissue 
the same processes occur as we have learned take place in interstitial in- 
flammation. Now small round cells are seen, now spindle cells, now 
epithelioid cells, then again products of regressive changes such as are 
characteristic of every inflammation. 




Figure 33. — Hyperteophic Endometritis (Fungosa). 

a, small-celled, infiltrated interglandular tissue ; h, sections through dilated glands 
with numerous depressions. 



Through the increase of the glandular epithelium an increased secre- 
tion of mucus takes place, and at times the gland lumina are filled with 
mucus and the excretory ducts are obstructed. If the mucus is not 
discharged, but is continually formed, there result cystic dilatations of 
the glands, and such cysts are frequently found in this form of in- 
flammation. 

Such cysts may be as large as a pinhead, so that in a microscopical 
section they are recognized with the naked eye, and occasionally such 



96 HYPERTROPHIC ENDOMETRITIS. 

sections have a sieve-like appearance. The epithelial cells are flattened 
by the increasing pressure and in some cases disappear, and occasionally 
the wall is lined with an endothelial-like membrane. The vessels take 
a decided part in this form of inflammation, for they also share in the 
general proliferation. The capillaries increase in number and in size; 
the plethora is considerable, so that blood is easily ponred out into the 
interstitial tissue. This trickles partly up to the surface through th^ 
epithelium of the superficial covering, which has often already de- 
generated, or else it passes through the epithelium of the gland walls 
and fills the glands as in Fig. 34. 

It is seen that in this process manifold and very dift'erent changes 
occur, at times coexisting, at times developing the one from the other, 




FiGUEE 34. — Htpertrophic Exdometeitis "WITH Bleeding into the Glands. 

a, small-celled interstitial tissue, with extravasations of blood in places (through the 
smaller, lighter cells the red blood corpuscles are seen) : 6, sections of glands filled en- 
tirely or partly with blood : c, invaginated gland in transverse section (the internal circle 
of epithelium is not entirely complete; some cells have fallen out). 

and it therefore happens that the microscopical pictures are not easy to 
understand. The gro^vth of the gland epithelium combined with oblique 
sections may be mistaken for a malignant neoplasm. The isochronous 
occurrence of spindle and epithelioid cells in the interstitial tissue some- 
times makes a diagnosis even more difficult, yet I think that sufficient 
practice enables one to distinguish this inflammatory condition from 
a malignant neoplasm. It must be kept in mind that in just such inflam- 
mations different stages of the aff'ection are present; and even though 
numerous chains of such cells be found in such a specimen, the study 
of many sections gives us a clear idea of the character of the entire 
complication. That examinations should never be confined to one or tvv^o 



DECIDUAL EXDOMETEITIS. \) i 

sectioiis in doubtf\il eases is. of coiirse. scarcely necessaiy to mention. 
In such cases it is better to embed such, curetted particles in celloidin 
on one cork, so that a section may present six to eight different areas 
united under one cover-glass. 

(X) Decidual Endometritis. 

•Just as the endometrium may become affected in the non-pregnant 
state, so may it be the seat of inflammation during pregnancy and sub- 
sequently. As a rule, it is the continuation of previously existing endo- 
meti'itis. yet during pregnancy inflammation may also be the result of 
septic (artificial, criminal abortion) or gonorrheal infection. The de- 
cidua is then thickened in foto or shows polypoid formations (polypoid, 
decidual endometritis). The inflammation is confined principally to the 
interstitial tissue, and the decidua cells are pushed apart by numerous 
round cells or through increase of the connective tissue (tlie scirrhous 
form) . 

Such inflammations lead to the retention of placental tissue when 
the ovum is expelled. Such placental remains unite very fii'mly with 
the decidua and after the termination of pregnancy may continue their 
growth (placental polyps). [Microscopically there are found in such 
polyps chorionic villi and the products of the inflammation jiist de- 
scribed. 

C. Hyperplasia. 

By hyperplasia we undei^tand a growth of the mucous membrane in 
which none of the above-described inflammatory products, small-celled 
infiltration, etc.. can be recognized. In all cases the entire mucous 
membrane is thickened or only parts of it. The latter form results in 
polyps situated on the mucous membrane, either pedunculated or sessile. 
If the intei'^titial tissue and the glands are both affected we are deal- 
ing with 

(a) Hyperplasia of the Whole Endometrium. 

which is of two forms : 

{oc) Diftuse H^-ijerplasia of the W liole Endoiuetrium. 

Here the entire mucous membrane is proliferated, so that the inner 
surface of the uterus is clothed with a thick lining. The individual 
elements of the mucous membrane are inci'<?ased in number and size with 
active participation and new gi*owth of the vessels. A unifonn par- 
ticipation of the entire mucous membrane is here as rare as in inflam- 
mations, ^lore frequently partial proliferation is observed, and in such 
cases we speak of 

(p) CirctLiiis>cribed Hyperplasia of tlie "Whole Endometriiiin (Polyposa). 

Here is found a localized gro"^vth in which all of the elements of the 
mucous membrane are increased in number and in size, and this growth 

7 



98 



HYPERPLASIA OF THE ENDOMETRIUM. 



projects above the rest of the mucous lining like a polyp. Fig. 35 shows 
these relations better than can be done by description. 

We see clearly the outlined polypoid formation (a) projecting above 
the surface of the mucous membrane (h). In the lower layers of this 
mucous membrane (this is a curetted particle) it is seen that fibrous 
strands are present between the partially dilated glands. These bands, 
when strongly magnified, are seen to be muscle fibres. The growth itself 
is marked off from the rest of the mucous membrane by a zone of small- 
celled infiltration, and is therefore a pure polyp formation arising from 
the mucous membrane and at no point penetrating the muscular wall. 

In Fig. 36 this polyp, more highly magnified, shows the following 
changes : 

The cells of the interstitial tissue (e) are plainly seen to be uniformly 



a 











Figure 35. — Ciecumsceibed Htpeeplasia of the Whole Endometeium (Polypoid) (en- 
larged 4c x). Explanation in text. 



increased without the presence between them of small-celled infiltration. 
Although increased in number their previous form and size are well 
preserved. At Z> a group of large cells is seen between the other cells. 
This is a section through the fundus of a gland. The glands are in- 
creased in number and some of them are dilated. Their epithelium has 
proliferated in certain spots, so that the wall is lined with several layers, 
as at d. The most noticeable change is the presence of numerous vessels. 
We see arteries (a) and veins (aj, and also numerous sections of vessels 
which cannot be distinctly classified, but which are easily recognized 
from their structure. At c is seen the point of division of a vessel. 
This new formation of arteries and veins is always found in such poly- 
poid formations. While in the endometrium very fine capillaries, and 
especially venous capillaries, are intended to carry off the blood as 
much as possible, here the ncAvly formed arterial and venous branches 



HYPERPLASIA OF THE GLANDS. 



99 



have a tendency to stimnlate the growth of these polyps to a decided 
extent. The irritation caused by this new formation leads to a hyper- 
emia of the other portions of the mucous membrane. In this way it may 
be understood why these polypoid formations are usually accompanied 
by profuse uterine bleeding. 

If only the glands take part in the hyperplastic changes we are then 
dealing mth 

(h) Hyperplasia of the Glands of the Endometrmm. 
This is di^dded into two forms : 




FiGUEE 36. — From the PoLyp 



IN FiGUEE 35 (strongly magnifledj. 
text. 



Explanation in 



(oc) Diflfiise Hyperplasia of tlie Glands of tlie Entlometi'iuin. 

The entire endometrium increases in thickness as a result of an ex- 
cessive growth of glands. The glands are so increased that eventually 
the interstitial tissue is reduced to a minimum, and finally between every 
two glands only one layer of cells is found, and nothing of an inflamma- 
tory character is to be observed. The epithelium of the glands often 
covers the walls in numerous layers, but preserves its cylindrical form. 
These hyperplastic formations differ from the destructive glandular 
neoplasms in that the glandular form is always preserved and tlie epi- 
thelial cells ahvays respect the Ijoundary formed hy tlie memhranal 
propria. The whole gives an impression of regularity and reflects the 
typical gland character. 



LofC 



100 NEOPLASMS. 

The second form represents almost the same structure, with the dif- 
ference that only a part of the entire mucous membrane is concerned. 

(/5) Circvimscribed (Polypoid) Hyperplasia of tlie Glands of the Endometrium. 

This polypoid formation, as we have just studied it, occurs with 
atrophy of the interstitial tissue and consists exclusively of glands. This 
is a relatively frequent affection. Its finer structure is the same as that 
which we have explained under hyperplasia of the glands of the entire 
mucous membrane. The same characteristics of benignity exist in both 
forms, so that it is not necessary to go into further explanations. With 
these new formations the limit of clinically benign and anatomically 
homologous neoplasms is reached. As soon as the growth goes further 
and the borders of the different tissues are no longer respected we are 
dealing with a destructive neoplasm. These often cause great difficulty 
in diagnosis if only small particles are examined. 

D. Neoplasms. 

Having already divided the affections of the endometrium in a man- 
ner of practical value for our purposes, we are now to touch upon the 
clinically malignant neoplasms. Since the microscopical diagnosis in 
such cases may lead to a dangerous operation, it is clear that only such 
cases should be reported to the clinician as malignant and suitable for 
radical operations as present the strictest evidences demanded by diag- 
nosis. In the first place, the interest of the patient demands this; and, 
secondly, it is to the interest of science, for if the pathologist in examining 
curetted particles makes the diagnosis of malignant neoplasm, and if 
the removed organ does not substantiate this diagnosis, it is a scientific 
falsification, for such cases are classed as having been cured by oper- 
ation. So long as we do not know the specific cause, only the general 
characteristics of these malignant neoplasms hold good. If a small piece 
curetted from the uterus does not suffice for recognition of this affection 
3ve can only say "non liquet." It then remains for the clinician to de- 
cide what should be done. We have already mentioned that clinical ob- 
servation is frequently an essential support to the microscopical diag- 
nosis. The malignant neoplasms of the endometrium originate either 
from the epithelium or from the connective tissue. The epithelial neo- 
plasms (adenoma and carcinoma) develop, as a rule, from the epithelium 
of the glands, but recent investigation has shown that they may de- 
velop from the cylindrical epithelium of the surface. The connective- 
tissue neoplasms (sarcoma) develop from the cells of the interstitial 
tissue. 

(a) Carcinoma of the Endometrium. 

For the diagnosis of carcinoma of the uterine mucosa, which is of less 
frequent occurrence than that of the vaginal portion of the cervix, the 
same rules hold good as for the latter. It would, therefore, be a repeti- 



CARCINOMA OF THE ENDOMETRIUM. 



101 



tion were I to mention again these various points. A carcinoma is al- 
ways (sometimes with modifications in structure, such as cancroid, col- 
loid carcinoma) a formation of epithelioid elements in a connective-tissue 
basis. The boundaries of the remaining tissue are not respected by the 
neoplasm, for the latter grows, in atypical form, into the glands and 
vessels without stopping at their enveloping membrane. A piece of 
curetted mucous memljrane is sufficient for this diagnosis, for in the 




<z 



FiGUEE 37. — Carcinoma of the Endometriuini. 

a, gland sections with growth of epithelium ; li, carcinoma nodules ; d, interstitial tissue 
consisting of spindle cells, between which scattered round cells are found. 



mucous membrane are various tissues from which we may easily see the 
variations of a neoplasm if the structure of this neoplasm is fully pro- 
nounced. No one can hesitate to recognize in Fig. 37, a curetted particle, 
the presence of a carcinoma. 

The drawing presents several very important and characteristic areas. 
We see the easily recognized cancer area (h) and also changed glands. 
In these "cancer cones" we recognize epithelioid cells of various sizes. 
As the lighter color of the drawing shows, they have taken on the hema- 



102 * CARCINOMA OF THE ENDOMETRIUM. 

toxylin stain less intensely than the remaining tissue and the cells lining 
the glands. The sharply • outlined areas lying in the centre of these 

cancer cones, ' ' should be noticeable, especially to the beginner. 

In the cancer cone (h) this distinct zone represents unchanged cells, 
while in the other ' ' cones ' ' only cell detritus can be seen. Such central 
softenings often occur in carcinoma and are described by all examiners. 
Sometimes no cells or cell remnants are seen in the centre, but, instead, 
cavities sharply outlined by an endothelial membrane. Certain ex- 
aminers consider these to be capillaries. In such a case the carcinoma 
would be filling the perivascular lymph vessels. 

The changes in the epithelium of the glands (a) are important. It 
is seen that the former cylindrical cells line the wall of the gland in 
stratified layers. The form of the epithelium appears changed, and the 
nucleus larger than usual. This is especially the case in the gland which 
lies at the right hand lower corner of the draA^dng. In the upper gland, 
on the contrary, the changed form of the cells is doubtless caused by an 
oblique section. The growth of epithelium in the glands is an event oc- 
curring with every irritation of the mucous membrane, as has already 
been shown in various places. On the other hand, this growth has been 
considered to be the beginning stage of a carcinoma arising from the 
glands, so that when such changes are found in a curetted specimen a 
diagnosis of a "beginning carcinoma" is made. I cannot advise too 
much caution in guarding against such a diagnosis. I agree with Orth 
when he says, in discussing the diagnosis to be made from small bits of 
tissue, that "the presence of irregular alveolar cavities filled with epithe- 
lial cells, or of reticular epithelial cords, perhaps with pearls, is proof 
of a carcinomatous neoplasm and demands total extirpation; while, on 
the other hand, various forms of proliferation in the glands, situated in 
the general tissue groundwork, twistings, dilatations, formations of papil- 
lary protruding folds in the lumen, and even the filling of the lumen 
with cast-off cells, do not of themselves permit a positive diagnosis of 
malignant neoplasm." 

A sufficient proof of the malignancy of the process, if typical alveoli 
are not present, is furnished if these growths of the epithelium do not 
take place inside the glands, but break through the membrana propria 
and penetrate into the interstitial tissue; and yet I mention again that 
before the diagnosis of a perforation through the membrana propria is 
made, all means at our disposal must be used to determine whether we 
are not dealing with an illusion caused by the plane of the section. 

(h) Malignant Adenoma of the Endometrium. 

The diagnosis of an adenoma in an excised uterus is not difficult. We 
are then dealing with a tumor formation which is made up of glandular 
structures, consisting of tubes lined with cylindrical epithelium placed 
next to each other vdth very little supporting material and not confined 



MALIGNANT ADENOMA OF THE ENDOMETRIUM. 103 

to tlie mucous membrane alone, bnt either continned further into 
the underljung muscle, and in older cases sometimes even breaking 
through the peritoneum, or else continued irregularly in the muscle as 
nodules of the same anatomical character. T\lien of long-standing, there 
results the formation of solid epithelial strands, so that we are no longer 
dealing ^^uth a ptire adenoma but Avith an adenocarcinoma. 

The diagnosis from curetted particles is more difficult, anrl at iirnes 
impossible. As we liaA'e seen, there occurs at times with pure hyper- 
plasia of the glands a very excessiye increase in their number. TMiat 
has already been shown is that this latter form always preserves ilie 
original gland type. In the case of a destructive adenoma Ave are deal- 
ing no longer with glands but T^uth epithelial strands. These retain at 
the beginning a lumen, but assume atypical shapes which no longer re- 
semble the uterine glands, possess no menibrana propria, and lie close 
together. Ziegler says: ''The microscopical examination of small 
pieces can define the neoplasm, in that the tissue of an adenoma 
follows the gland type, but does not reprodtice exactly the type of glands 
normallv found in the orsan concerned. ' ' Orth savs : ' ' The discoA'erv 
of glandular tubes lying close together, especially when the normal 
boundary formed by a tunica propria and longitudinal muscle fibres is 
absent, is in my opinion enough to justify the diagnosis of malignant 
neoplasm and to indicate the need of total extirpation." 

I would mention, as especially characteristic, the fact that in such 
adenomata we are no longer dealing with the original ciliated cylindrical 
epithelium of the uterine mucous membrane. The epithelial strands con- 
sist of closely grouped cubical cells which are rounded like an eg^ and 
are frequently irregular in form. The small nucleus hung usually at the 
base is decidedly enlarged at the expense of the protoplasm. The cells 
lie irregularly next to each other,, without showing a defined line of de- 
marcation from the interstitial tissue. 

The clinical condition is an essential support to the microscopical 
diagnosis in this case. If. in examining the uterine cavity with the finger. 
a soft, circumscribed tumor is felt, from which brittle pieces may be 
loosened, and if these pieces show the microscopical condition just de- 
scribed, we are justified in undertaking a radical operation. The stib- 
sequent examination must then decide whether the previously diagnosed 
form of neoplasm was present. If. however, a circumscribed tumor be 
not felt and we are perhaps dealing w^th the affection in its first stages, . 
then the microscopical examination does not suffice, since in curetting we 
cannot remove the deeper layers of the muscle withotit danger of per- 
forating the uterus. The deep extension of the glandular neopJasni into 
the muscle is, then, the only criterion of the malignancy of the neoplasm. 

It has been claimed by Ruge and others that it is often too late to 
prevent recurrence if this last criterion is always waited for. This may 
be true, but, on the other hand, we must consider that if the uterus 



lOJ: sai?co:ma of the exdometrit:^. 

be removed because of a diagnosis of "begiimiiig malignant adenoma'* 
(pure gi'owth of glands without the t^-pical formations of carcinoma), 
and then no area is found in the excised organ which substantiates the 
ni'st diagnosis and the patient does not suffer from a recurrence, no 
proof is furnished that a malignant neoplasm has been removed. 

In my opinion this diagnosis, as well as the diag)iosis of sarcoma made 
from curetted particles, is the most difficult which has to be made in 
this line. Even the most practised and one who has had great ex- 
perience can male these errors. AVe are often compelled to say that 
in the pieces given to us for examination we do not find the necessary evi- 
dences of the presence of a malignant neoplasm. The clinician, on the 
other hand. will, in spite of this, as a result of his experience and liis 
observation, remove the organ and fimd a well-defined malignant neo- 
plasm. And the opposite is just as likely to occur. As yet our micro- 
scopical knowledge of the first stage of these changes is not sufficient to 
justify an absolute decis^ion in all cases. 

(c) Sarcoma of the Endometrium. 

The same dijQBculties confront us in the diagnosis of a sarcoma as 
in the case of an adenoma. Here also, if a large ttmior is at our disposal 
for microscopical examination, a diagnosis can be made without diffi- 
culty according to the recognized criteria, for it is a tumor rich in cells, 
which, according to our present views, has developed from the cells of 
the connective tissue. According to the form of the cells we distinguish 
round-celled, spindle-celled, and giant-celled sarcomata. It should not 
be understood that the tumor must consist exclusivelv of one or the other 
form of cells, for usually the variotis cell forms are present, of which 
only one is especially marked. The uterine glands are generally de- 
stroyed in the sarcoma, so that the tumor consists entirely of cellular 
elements and vessels. 

"W^ith reference to the seat of origin we distingtiish two forms, sar- 
coma of the mucous membrane and sarcoma of the wall. 

{oc) Sarcoma of tlie 3-IticoTis Memljrane. 

The mucous membrane is either completely involved by the neoplasm 
(sarcomatous degeneration), or there results a circumscribed tumor. The 
latter are ustially polypoid formations which fill the titerine cavity and 
may enter the vagina through the cervical canal. By edematotis infil- 
tration or myxomatous degeneration there may result here, as in the 
cervix, the grape-liJie sarcomata. In these are found both glands and 
cysts : as a rule the glands ai;e destroyed relatively early. The neoplasm 
originates from the cells of the stroma, which take on most varying cell 
forms. Most frequently round-celled sarcomata are observed. 

(p) Sarcoma of tlie Uterine "WaU. 

The sarcomata which begin in the wall of the uteriLS are. as a rule, 



DECIDUOMA. 105 

sarcomatous degenerations of myomata (myosarcoma j . Their malig- 
nancy is shown by the sudden rapid growth and by the formation of 
localized metastases in the early stages. The location at first corresponds 
to the seat of the myoma. Then the sarcoma grows toward the nterine 
cavity and a sanions degeneration of the surface layers occurs. On the 
peritoneal surface of the uterus are formed numerous nodules, which 
extend to the parietal peritoneum and cause metastases in other organs. 
These sarcomata are usually spindle-celled. They are derived from the 
muscle cells or the cells of the interstitial connective tissue or the en- 
dothelium of the vessels. 

Since these sarcomata of the uterus are usually malignant and 
Cjuickly cause an enlargement of the organ by their infiltration of the 
wall with tumor nodules, the existence of such a cJi/iical and microscopical 
condition makes the diagnosis cpnte certain. The diagnosis from a cu- 
retted particle "without any clinical evidence is uncertain, for we have 
seen that the cells of the interstitial tissue may take on all possible 
forms in an inflammation. At any rate, it must be mentioned that, as a 
rule, different stages of inflammation are present at the same time, such 
as degeneration, etc. The sarcomatous neoplasm, on the other hand, is 
free of any inflammatory mixture. An especial proof of the anatomical 
malignancy of the process is the existence of areas in Avliich the sarcoma 
breaks into glands or vessels. 

The condition of the glands is important, as in inflammation of the 
interstitial tissue the glands usually show no or else unimportant 
changes, whereas in sarcoma they may be destroyed relatively early. 

(d) The Destructive Neoplasms Arising in Connection iritli Pre g nancy. 

The tumors of the uterus arising in connection with pregnancy have 
caused considerable discussion in later years. To simplify matters. I 
would recommend, in agreement Avith AValdeyer. the following classifi- 
cation : According as the neoplasm takes its origin from maternal or 
fetal tissue, we distinguish deciduoma or chorioma. 

(oc) Deciduoma. 

As we have seen, destructive neoplasms may take their origin from 
the endometrium. The same may occur when the endometrium has been 
changed by pregnancy into a decidua. If the neoplasm originates from 
the epithelial elements of the decidua (gland fundi), there is formed a 
carcinomatous or adenomatous deciduoma. If. on the contrary, the 
neoplasm originates from the connective-tissue elements, there is formed 
a sarcomatous deciduoma. 

These tumors are then to be considered as ordinary sarcomata or 
carcinomata which occur during or after pregnancy. On the other hand, 
those tumors of the gravid uterus which originate from the fetal elements 
(chorion^ form a separate group. 



106 CHORIOMA. 

(p) Cliorioma (Waldeyer). 

Sanger was the first to call attention to this affection and to recog- 
nize it after like cases had been described by R. Maier. At the time of 
the publication of the first edition of this book only a few works con- 
cerning this subject had been published, but in later years a large 
amount of literature has appeared, more than one hundred separate 
articles. In spite of this fact there is no agreement with regard to the 
histogenesis of the tumor, so that my observation of four years ago, to 
the effect that many questions connected therewith remain to be 
answered, holds good to-day. 

In chorioma we are dealing with a tumor which develops in connection 
with pregnancy (abortion), from the chorionic villi, and which, through 
early metastases into other organs, usually leads to an early death. The 
propagation of these metastases occurs, as a rule, through the blood 
channels. According to a table of Eiermann, of thirty operated cases, 
six remained free from recurrence after two years or more. This shows 
that it is possible to operate in time, if only the diagnosis is made suffi- 
ciently early. This is possible, from our present knowledge of the neo- 
plasm, by comparing the clinical and the anatomical conditions. 

In the microscopical picture are found cords and strands of proto- 
plasmic masses with numerous nuclei and vacuoles (syncytial masses), 
which branch frequently and are connected with each other in a reticular 
manner. This forms larger and smaller mesh spaces, in which various 
large cell elements with large nuclei, and also polynuclear giant cells, are 
present. In the tumor are found many blood extravasations into the tissue 
and numerous irregularly formed spaces which are to be considered as 
blood spaces. In addition necrotic areas are usually present. These are 
remains of the syncytial trabecular formations, whose outline can no 
longer be recognized, but whose nuclei are preserved. 

Clinically it should be mentioned that the growth of this tissue does 
not take place mainly toward the uterine cavity, as in sarcoma and car- 
cinoma, but toward the uterine muscle. Gottschalk was the first to give a 
very exact microscopical description of this neoplasm. He found, in a 
case, distinctly recognizable chorionic villi and these same structures in 
the metastases. The villi showed their connective-tissue centre as well as 
their syncytial (epithelial) covering. Since the connective-tissue centre 
was richer in cells than normally, he, in agreement with Waldeyer, laid 
great stress upon this fact and considered the neoplasm to be a sarcoma. 

This evoked contradiction from other examiners, who believed that 
the tumor originated from the epithelial elements of the chorionic villi, 
and for that reason considered it to be a carcinoma. This is the general 
opinion at the present time, the result especially of the works of L. 
Frankel and Marchand, which view is also shared by Ruge. Whether 
this view is correct in all cases seems to be doubtful; at any rate, the 
credit due Gottschalk in recognizing this condition cannot be diminished. 



CHORIOMA. 107 

With, regard to the histogenesis of the neoplasm, it cannot be said 
^vith certainty whether we are concerned with an epithelial or a con- 
nective-tissiie formation, until complete light is thrown upon the origin 
of the layer which covers the ^dlli. 

As yet this has not been done. On the contrary, we find diametrically 
opposed opinions. According to my investigations, which were made 
on very young placentae in cases of tubal gestation, the covering of the 
villi in their earlier stages is made up of three layers (see Fig. 31). 
The stroma of the ^illi. made up of embryonal connective tissue, is cov- 
ered by a double layer of round cells. This is of ectodermal origin and 
must be considered the double epithelial coating of the villi. Upon this 
lies a layer of long cells, which, in my opinion, represent the endothelium 
of the maternal blood vessels. This is pressed forward into the inter- 
villous blood spaces by the growing villi like the fingers in a glove. If 
this external covering of the chorionic villi is not fetal but maternal, it 
belongs nevertheless topographically to the villus, and must be considered 
as belonging to it. Pfannenstiel has expressed the opinion that this 
layer, originating from the endothelium of the vessels, forms the subse- 
quent s}Tic^i:ium: the above-mentioned double cell layer hi^ng under- 
neath it becomes later a single layer (the layer of Langhans) and rep- 
resents the epithelium of the villi. This view may be accepted. 

It is seen that the origin of tumors of the chorionic -sdlli may vary. 
If only the epithelium is taken into consideration the neoplasm must 
be reckoned ^^ith the carcinomata; if the tumor originates from the 
stroma of the villi it is a sarcoma, and if the epithelium is also affected 
it is a sarco-carcinoma. 

If the tumor is derived from the s^Ticvtium we mav call it chorioma 
syncytiale, or. in consideration of Pfannenstiers view, chorioma endo- 
theliale, reckoning the sjmcytium topographically as part of the villus, 
although we admit that genetically it belongs to the maternal part of the 
placenta. 

In the numerous descriptions in the literature, and in comparing the 
same with my specimens, it seems clear that we are dealing with a 
specific neoplasm of the chorionic ^dlli. but that from case to case we 
must decide whether the same is a carcinoma, a sarcoma, or a mixed 
tumor. For that reason Waldeyer proposes to call this neoplasm chori- 
oma, whereby it is simply said that all the elements which compose the 
^'illus may be concerned in the neoplasm. The name chorioma seems 
to me the most suitable, in that it mentions the characteristic feature. 
Under chorioma come those cases in which the connective tissue of the 
stroma is concerned in the growth, as well as those cases which consist 
mainly of sjTicytial or epithelial (the layer of Langhans) growths. If 
the microscopical examination decides from which part of the chorionic 
^411i. in any case, the neoplasm originates entirely or in part, we may 
call it chorioma carcinomatosum. sarcomatosum or sarco-carcinomatosum 



108 TUBERCULOSIS OF THE ENDOMETRIUM. 

or syncytiale endotheUale. The difference of opinion concerning the 
origin and make-np of the tumor may be seen in the various names which 
I have gathered together from historical interest : 

Deciduoma malignum, sarcoma deciduo-cellulare, sarcoma of the 
chorionic villi, sarcoma of the chorion, malignant placental- villous tu- 
mors, sarcoma chorion-deciduale, deciduo-sarcoma uteri giganto-cellulare, 
serotinal tumor, carcinoma syncytiale, choriocarcinoma, syncytioma ma- 
lignum, epithelioma syncytio-ectodermale or epithelioma ectodermo-syn- 
cytiale, epithelioma ectodermale. 

With regard to the diagnosis I should like to mention the declaration 
of Sanger "that it is always necessary to examine the uterine cavity 
with the finger after dilatation of the cervix, which is another ground 
for giving up the objectionable, uncertain, and dangerous curetting of the 
uterus for retention of membranes, as is usually done. ' ' It is, therefore, 
advisable, as I have often pointed out, to accept the view that the tactile 
examination of the uterine cavity is an important aid in deciding the 
meaning of the microscopical condition. 

(e) Tuberculosis of the Endometrium. 

Though tuberculosis of the endometrium belongs primarily to the 
rare cases, it occurs occasionally. The clinical symptoms are such that 
the distinction between it and a malignant neoplasm is not always an 
easy task. In the microscopical examination of a piece of mucous mem- 
brane we find the well-known tubercles with giant cells which we have 
illustrated in tuberculosis of the vaginal portion of the cervix, in which 
it is sometimes possible to stain the tubercle bacilli. 

Naturally, if we do not obtain a positive result at first, numerous 
sections must be stained, for the presence of tubercle bacilli is un- 
doubted proof. If, however, they are not found, the anatomical structure 
of the tubercle is sufficiently characteristic to prevent confusion with 
other affections. The interstitial tissue shows either decided small- 
celled infiltration mth hyperplastic formations of gland epithelium, 
in the early stages, or else it changes to granulation tissue with simul- 
taneous atrophy of the glands. If the diagnosis tuberculosis is made, 
radical operation should follow, just as with malignant neoplasms, pro- 
viding that other tubercular involvements can be excluded. But even if 
a slight affection of other organs is present (glands, lungs) we may yet 
hope that, after checking the loss of blood due to tuberculosis of the 
endometrium, the affection of the other organs may be more easily 
healed. 

B. THE WALL OF THE CORPUS UTERI (MYOMETRIUM). 

1. Inflammation (Metritis). 
In the connective tissue situated between the muscle bundles in- 



MYOMA OF THE UTERUS. 109 

flammation may occur, usually coming from the endometrium, in rare 
cases from the serous covering of the uterus. In acute inflammation 
there is a large accumulation of leucocytes, which force the muscle 
bundles apart and cause, by serous transudation, a doughy swelling of 
the uterus. One of the most frequent causes of this affection is gon- 
orrhea, but it may also be caused by septic infection. 

In these cases there may result the formation of abscesses in the 
wall, sometimes of great size. By a demarcating suppuration, a large 
portion of the wall may be thrown off (metritis dissecans), this usually 
bringing about the process of healing. 

Chronic inflammation leads to the development of much connective 
tissue between the muscle fibres, which become more and more atrophic 
the longer the process lasts. Eventually the entire muscle may dis- 
appear and the uterine wall, thickened by the formation of connective 
tissue, is changed into a hard mass. In this way certain bleedings may 
be explained, for the blood vessels, which are usually compressed by the 
contraction of the muscle, gape in the inflexible connective tissue, which 
possesses no contractile power. 

2. Neoplasms (Myoma^ Fibromyoma). 

In the wall of the uterus myomata find their principal seat. They 
originate directly from the muscle and are situated either directly under 
the mucous membrane (submucous myoma) or deeper in the wall (in- 
terstitial, intraparietal, or intramural myoma), or, finally, close under 
the peritoneum (subserous or subperitoneal myoma). The first and last 
forms may become pedunculated and form polyps. The intramural myo- 
mata may occur in various portions of the wall at the same time and 
cause, as is well known, immense tumors. Histologically speaking, pure 
myomata rarely occur. Connective tissue is always found in addition to 
muscle fibres. The endometrium shows, as a rule, changes of a hyper- 
plastic character, especially a decided increase in the glands. 

Not infrequently epithelial formations are found in the myomata. 
These originate either from the uterine glands, which then show cystic 
dilatation, or else are to be considered as remnants of the Wolffian lody 
and duct (v. Recklinghausen). (See page 161.) 

Various changes may occur secondarily in myomata. There may 
occur edematous infiltration of the myoma, accumulations of fluid in the 
dilated lymph spaces (lymphangiectatic fibromyoma, fibrocysts). In 
place of serous fluid the tumor may show extravasations of blood in its 
interior (cavernous fibromyoma). 

There may also occur fatty, hyaline, or myxomatous degeneration, or 
necrosis or suppurative degeneration of the myomata. In the latter case, 
as in metritis dissecans, whole layers may be expelled, causing much 
difficulty in the way of microscopical diagnosis. Finally, calcification of 
the myomata must be considered. Either calcium concretions are found 



110 FALLOPIAN TUBES. 

in the interior of the myoma or there is formed a more or less com- 
plete calcium shell around the tumor. 

That myomata may undergo sarcomatous degeneration has been al- 
ready mentioned under sarcomata. In this way mixed tumors result, 
especially if in a myoma glandular structures are also present (adeno- 
myosarcoma). From this form a carcinoma may develop, which is also 
to be considered a mixed tumor ( adenocarcinomatous myoma). 



V. TUBES. 

1. NORMAL ANATOMY. 

(a) Position and Course. 

The Fallopian tubes, also called oviducts, are tubes which furnish 
the connection between the ovary and the interior of the uterus, and 
are designed to convey into the uterus the ripe ova expelled from the 
ovaries. The tubes are organs symmetrically arranged, and begin their 
course from both corners of the uterine fundus. After they penetrate 
the mucous membrane they pierce the muscle wall of the uterus in a 
slight arch, ascending a little from their origin at the mucous lining, 
and then run nearly parallel to the upper surface of the uterus above 
the round ligament into the abdominal cavity. Here the tubes keep this 
-course for a short distance and then make a horseshoe turn backward 
and downward, so that the abdominal opening, with its adjacent ovary, 
lies more posterior than to the side of the uterus. This normal situation 
of the tube was first shown in the excellent topographical representations 
of His and Waldeyer. Only by considering this situation as the normal 
can a clear idea of the occurrence of many pathological processes be 
gained. The picture- which has appeared in all text books, in which 
the tubes, with the broad ligaments of the uterus, bounded the latter 
like the wings of a butterfly, tended to give a false impression of the 
normal situation of the sexual organs. For instance, it was impossible 
from such an illustration to understand how the so-called "external 
migration" of the ovum could take place. It is necessary in making a bi- 
manual examination to know where the tubes and ovaries are supposed to 
be. In my lectures I have frequently had the opportunity to see that 
l)eorinners had a false idea of their relations. 



•'&-' 



(b) Classification of the Various Sections of the Tube. 

We distinguish in the tube an interstitial portion, the isthmus, the 
ampulla, and the fimbriated end (infundibulum). 

By the interstitial portion we mean that part which runs through 
the uterus. It is distinoruished from the uterus as a distinct annular 



FALLOPIAN TUBES. 



Ill 



structure perforated by a canal as fine as a hair. This canal is con- 
siderably narrowed by longitudinal folds, which in this portion are un- 
important, but which through the formation of accessory folds become 
more numerous the nearer we approach the abdominal end. The muscle 
in the interstitial part appears to consist of a layer of circularly arranged 
fibres, while a longitudinal layer is not present. The mucous mem- 
brane consists of a thin layer of round cells, and has an epithelial cover- 
ing of ciliated cylindrical cells, which likewise cover the mucous lining 
of the entire tube. The movement of the cilia is from the abdominal end 
toward the uterine ostium. 



^-: 







,%s,,^^^ 



a 







d 






b\ 






e 



%?;-, 



->sesw^3jS5««%*W 



^^ii^S^k'^s^^S 



^^^HrinfM 



Figure 38. — Interstitial Portion of the Tube. 

Below the large vessel lumina (a) (branches of the ovarian artery and vein) is seen 
the annular tube (h). The lumen is lined with cylindrical epithelium. The structures 
(c) in the tube lumen are sections of fqlds ; cl„ muscle of the uterine fundus. 



After leaving the uterine wall the tube runs as an independent 
structure in the upper angle of the broad ligament, and appears as 
a smooth round cord of the thickness of a lead pencil at the uterine 
end, while at the abdominal end its circumference is twice as great. The 
average length of the tube is ten to twelve centimetres, but variations 
occur. 

The isthmus of the tube, as the part from the uterine border up to 
the point of turning is called, is distinguished from the so-called "am- 
puUa" only by the slighter development of the individual layers. The 
structure of the wall is the same in both parts. From without inward we 



112 



FALLOPIAN TUBES. 



distinguish a serous covering ; a layer made up of loose connective tissue 
in which the large vessels run, and generally called subserosa; the 
muscularis and the mucous membrane. It should be mentioned that the 
connective tissue of the ampulla is richer in cells. The folds here are 
larger than in other parts of the tube. 

The serous covering is as firmly united to the underlying layer as 
is the case in the body of the uterus, and for that reason it can be 
peeled off with difficulty. Upon this covering is a densely branching net 
of lymph vessels (Poirier). 



■'^^^ 




v^ 



. ) 












FiGUEE 39. — Isthmus of the Tube (near the ampulla), 
a, muscle ; h^ folds ; Cj tubal canal. 



The muscle consists of an external longitudinal and an internal 
circular layer. The latter sends extensions to the mucous membrane, to 
the four principal folds which extend along the entire length of the 
tube. No muscle fibres extend to the finer divisions of these folds. The 
muscular development is relatively weaker at the abdominal than at 
the uterine end. The increase in thickness of the abdominal end is 
caused only by the numerous ramifications of the mucous membrane 
folds. Between the muscle bundles are found everywhere bundles of 
loose connective tissue in which the muscles and nerves extend to the 
mucous membrane. 



FALLOPIAN TUBES. 



113 



The mucous membrane is situated directly upon the muscle, so that, as 
in the uterus, no submucosa exists. The cells which lie in the mucous 
membrane of the tube resemble the stroma cells of the uterine mucous 
membrane, but are smaller than these and lie very close together. Be- 
tween them lies a very delicate connective-tissue meshwork. The stroma 
cells give the impression of lymphoid cells. 

The mucous lining of the tube does not bound the canal in a straight, 
even surface, but forms longitudinal elevations. In the region of the 
abdominal opening these elevations with their small accessory folds reach 
such a high grade that one can no longer recognize a central canal. In 



/ 



^r^-^- 






^"'^ " 






'.Mi ^7- 



'^^'■■^%k 







a 



b 



a 



Figure 40. — Fimbriated Ekd or the Tube. 

Blood vessels (c) ; lymph vessels (a) dilated. The epithelium at certain points (h) is 
absent. 



transverse section one gains the impression of villi with numerous 
branches extending toward the tube lumen from all sides of the mucous 
membrane. Through adhesion of these numerous accessory folds, and 
by oblique sections, pictures easily result which may be mistaken for 
gland sections. It must be held in mind that in the normal tubal 
mucous lining neither glands nor villi are present. 

The covering of the mucous membrane is formed by a very regular 
ciliated cylindrical epithelium. The cells are somewhat thinner than 
those of the uterine mucous membrane, but not so long as those in the 
cervical. 

8 



114 



TUBES DURING MENSTRUATION. 



The blood capillaries extend up to the epithelial covering. The finest 
branches of the lymph vessels have been seen here as well as in the 
^uterine mucous membrane. It is believed that simply tissue spaces are 
present, which only in the deeper layers unite to form lymph vessels. 

At the abdominal end the tube is open. The numerous folds of 
mucous membrane project from the interior and surround the opening 
like a ruffle, forming the so-called ''fimbria." One of these folds runs 
like a gutter to the ovary, the so-called "fimbria ovarica." The abdom- 
inal opening is not round, but oblique, and deepened like a funnel, and 
for that reason is called "the inf undibulum. " At the time of expulsion 
of the ripe egg an increased flow of blood to the tube takes place, and 
it is said that the funnel-shaped opening approaches the ovary on this 
account. It is the mission of the fimbria ovarica to conduct the ovum 
into the funnel, which is accomplished entirely by the movement of the 
cilia. It is therefore seen that the arrangement is such as to facilitate, 
as much as possible, the entrance of the ovum into the tube. 

(c) Changes Occurring within Normal Limits. 

The same changes as we have seen in the uterus, where the anatomical 
structure is liable to certain changes according to the age of the in- 
dividual or during menstruation or pregnancy, occur in the tubes. It 
may be said at once that these changes are like those in the uterus, but 
of less intensity. 

{oc) Menstruation. 

According to present investigations, it may be granted with certainty 
that at menstruation plethora exists. There results, though to a very 
slight extent, an effusion of blood in the tubal mucous membrane and 
the trickling of the blood into the tubal canal. Whether menstruation of 
the tube occurs, without uterine menstruation, seems doubtful, for we 
must consider that the results and observations concerning this question 
have always been derived from pathological cases. Experimental ex- 
aminations with ligation of the tubes at one or both ends have proved 
that secretion by the epithelium of the mucous membrane does not 
normally take place. Whether such a secretion occurs during menstru- 
ation has not yet been proven — i. e., under normal conditions. We are 
always limited, in judging these things, to observations after operation, 
where we are usually dealing with decidedly pathological states. At any 
rate, it has been observed, for instance, in stitching the stump of the 
tube into the wound, that at the time of the menses, at very regular 
intervals, the excretion of mucus or blood took place. I myself ob- 
served after a vaginal extirpation of the uterus that several weeks 
later a rather severe bleeding from the vagina took place. Since a sec- 
ondary hemorrhage could not occur, and since the time corresponded 
to that at which menstruation usually occurred, it seems probable that 
the menstrual congestion showed itself through such an effusion of blood 
from the tube. Nevertheless I would reject all these observations as 



TUBES DURIXG PREGXANCY. 115 

absolute proof of the existence of tubal menstruation under normal con- 
ditions. 

(/5) Senile Clianges. 

After cessation of menstruation, and as age advances, the tubes show 
certain senile changes. They are characterized by the shrinking of the 
connective tissue, a shrinking of the entire organ, and a decrease in 
the number of folds. The epithelium is preserved longest, even though 
the cells become individually smaller. The cilia like^vise disappear. 

(^) The Changes in Preg-nancy. 

During pregnancy the tube hypertrophies in all its parts, the mucous 
membrane mth its folds increasing especially. The vessels show a de- 
cided increase in size, especially the veins and the lymph vessels. Espe- 
cial changes of the indi\ddual tissues, such as the transformation of 
the uterine lining into decidua, do not seem, according to our present 
knowledge of normal intrauterine gestation, to occur in the tubes. Cases 
have, however, been described in which the connective-tissue cells of the 
tubal mucous membrane became enlarged and resembled the uterine de- 
cidua cells. With involution of the uterus involution of the tubes also 
occurs. 

2. PATHOLOGICAL AXAT0:MT. 

(a) Malformations. 

Only those malformations will be mentioned which are of importance 
in practice. In the first rank are : 

(oc) Infantile Tubes. 

Freund has pointed out the meaning of this condition in relation 
to the occurrence of tubal gestation. As is knoAvn, the tubes in an em- 
bryo show numerous spiral twists, which gradually disappear as the 
tubes and ovaries descend into the pehds, so that at puberty there 
are none in the normal tube. 

It is not infrequently observed that such spiral rotations of the 
tubes persist after full development of the genitalia and after puberty, 
in the absence of other pathological changes. Freund has given these 
cases the name of infantile tubes, and has repeatedly observed that the 
fecundated ovum is prevented by such twistings from entering the 
uterus, so that a tubal pregnancy results. Though some have doubted 
these claims of Freund, my own experience has confirmed them re- 
peatedly. The infantile tul)e is certainly one of the causes of tubal 
pregnancy. 

(B) -^cceasory Tubes and Tubal Ostia. 

In addition to the normal ostium abdominale of the tube, accessory 
openings have been observed, which like^^dse are lined Avith fimbriag. Ac- 
cording as these openings lie immediately in the tubal ivall, or are con- 
nected with it by a pedicle, which may or may not possess a canal, we 



116 TUBAL MALFORMATIONS. 

speak of an accessory ostium or an accessory tube. As a rule, these open- 
ings lie near the ordinary abdominal ostium, but may occur even midway 
between the abdominal and uterine ends. Recently I had occasion dur- 
ing a myoma operation to remove a tube which showed an accessory 
tube of almost the same length as the normal one. This showed, in ad- 
dition, the peculiarity of being divided at its middle into two parts, of 
which one joined the wall of the tube about one centimetre from the 
abdominal end, the other quite near the uterine extremity. These ac- 
cessory openings or tubes may communicate with the real tubal canal 
or end blindly. If a fecundated ovum makes its way into such a blind 
canal, it is clear that if the ovum develops an extrauterine gestation 
occurs. From these malformations are to be distinguished: 

(X) Hernial Dilatations (Diverticula) of the Tubal Canal. 

It occurs, though rarely, that canals lined with epithelium pass out in 
a straight or twisted course from the mucosa and penetrate the muscle 
more or less deeply, sometimes ending under the serosa. Such a canal 
may take a course perpendicular to the tubal canal and then bend on 
reaching the muscle, running for a certain distance parallel to it. 

These malformations also may furnish the cause of tubal pregnancy. 
In discussing these conditions, those so-called "supernumerary tubes," 
of which a few cases have been observed, must be kept in mind. We 
are dealing in these cases, as a rule, with a third tube connected with 
a third ovary or an ovarian tumor. These have been described as sep- 
arated from the genitalia and adherent to the omentum or other ab- 
dominal organs. Whether these were originally connected with the geni- 
talia and were freed from them later by inflammatory changes cannot 
be decided. Finally, in considering these malformations, I would men- 
tion a very frequently occurring formation known as 

{/!) Pedxinculated or Morgagni's Hydatids. 

These are small cysts of the size of a pea or walnut, filled with a clear 
fluid, which are either directly connected with the fimbriae or united to 
them by a longer or shorter pedicle. Opinions differ regarding their 
origin. The real cysts are said to be lined with the same epithelium as 
the fimbrige. No special pathological value is attached to these structures. 
(See Part III.) 

(b) Tubal Gestation. 

(a) Causes. 

The fecundated ovum may, under certain pathological conditions, be 
retained in the tube and there continue its development. As causes for 
this abnormal insertion of the ovum may be considered, in addition to 
those previously mentioned (malformations and arrests of development), 
all those changes which make the tube more or less impassable through 



TUBAL GESTATION. 117 

destruction of the cilia, and which make the transference of the ovnm by 
this means impossible. Contractions of the tube muscle (peristalsis) 
alone are not able to move the ovum through the tube into the uterus. 
For this, as is generally agreed, the movement of the cilia from the ab- 
dominal to the uterine ostium is necessary. The cilia may disappear as 
a result of affections of the tubal mucous memhrane. 

Another, and no doubt frequent, cause of tubal pregnancy is peri- 
salpingitic change. As a result of this, various parts of the tube be- 
come adherent to each other, to the uterus, the ovaries, the intestines, 
the omentum, and other organs of the abdominal cavity, contracting 
and twisting the canal so that it is absolutely impassable. In rarer cases 
obstruction of the canal by polyps of the mucous membrane or tumors 
of the tubal ivall has been given as the cause. Some authors place cer- 
tain tumors in the abdominal cavity, which compress the tubal canal, in 
a causal relation to tubal pregnancy. These permit the small sperma- 
tozoa with their active movement to pass through, but prevent the pas- 
sage of the fecundated ovum toward the uterus. The most frequent 
cause is an affection of the tubal mucous membrane (often gonorrheal). 

(b) Places of Insertion of the Ovum in the Tube. 

After exit of the ovum from the ovary, it must pass through the 
entire length of the tube, and may, if any of the above-mentioned con- 
ditions are present, remain in any portion of it and continue to de- 
velop. We therefore distinguish interstitial pregnancy , tubal proper, 
ampidlar, and infundibidar. In addition to these four main forms, 
of which the development of the ovum in the isthmus portion of the 
tube is the most frequent, transitions may occur, such positions being 
occupied by the ovum from the beginning or the transition forms oc- 
curring during its development. An interstitial pregnancy may occur 
at the boundary between the tube and the endometrium, and we then 
speak of a tubo-uterine pregnancy ; or at the abdominal end, when it is 
called a tubo-abdominal pregnancy. Finally, the insertion of the ovum 
may occur at the fimbria ovarica, as has been positively demonstrated. 

Certain changes peculiar to pregnancy take place in the tube as soon as 
a fecundated egg is implanted in it and undergoes development. These 
correspond only in part to the changes which we have learned in dis- 
cussing uterine gestation. The differences are the result of the essen- 
tially different structure of the tubal lining and the tubal wall. The 
latter is constantly stretched by the growing ovum, and finally forms 
only a connective-tissue wall such as results if the tube be changed to a 
cyst by other pathologically retained contents (serous fluid, blood, pus). 
The originally hypertrophic muscle disappears. In a more advanced 
tubal pregnancy we can for that reason recognize, as a rule, no tubal 
tissue, and this was the reason why so much was formerly said about 
"abdominal gestation." Only through examination of the early stages 



118 



DECIDUA BASALTS TUBAE. 



have we come to recognize that almost all these cases originate in the 
tube. 

The changes which we are now to discuss refer, therefore, only to the 
first weeks or months of tubal gestation. The further pregnancy ad- 
vances the more do these characteristic changes disappear, quite in con- 
trast to what takes place in the uterus. 



^%'M^t:m'r. 






wimx 













FiGUEB 41. — Change of the Tubal Mucous Membkane to a Decidua. 

a, decidua cells ; 1), round cells ; c, spindle-shaped connective-tissue cells ; d, intercel- 
lular spaces. 

(c) Changes in the Tubal Lining in the Region of the Ovum in Tubal 

Gestation. 

[O^) Decidua I3asalis of tlie Tube (Serotina). 

All examiners agree that at the point where the ovum rests the 
mucous membrane cells change into decidua cells. Although they do 
not reach the size of the uterine decidua cells, they resemble them 
very much in form. The cells have a delicate, transparent protoplasm 
and one or more relatively large nuclei, which distinguish them from 
squamous epithelium. They do not lie so closely together as in the en- 



DECIDUA VERA TUBAE. 119 

dometriiim. where in the upper layers they form the so-called ' ' compact 
tissue," but show between them cell spaces which are filled with a 
homogeneous substance. Between the decidua cells are frequently seen 
spindle-shaped connective-tissue cells of the ordinary size, and cells re- 
sembling the normal connective-tissue cells of the tubal lining, as well 
as numerous round cells. AYe thus gain the impression that the change 
of the tubal lining to decidua is not so complete as in the uterus. I 
could not prove in any case that the di^dsion into two layers, a compact 
and a spongy one, occurred, as we found to be the case in the uterine 
decidua. 

This is highly improbable when we remember that the spongy layer 
is formed by the dilated fundi of the uterine glands. AYe have seen 
that in the normal tubal lining no glands are present. There is not 
the slightest reason why we should assume that glands or gland-like 
structures should be formed during pregnancy, for the fundi of the 
glands in the uterus, which are preserved during pregnancy, serve to 
regenerate the glands of the endometrium and the epithelium of the 
surface after expulsion of the compact layer. In the tube, however, con- 
ditions are different. Glands are not formed, and the epithelial cells. 
which are lost at the point of insertion of the ovum and in its entire 
circumference, are regenerated by the growth of the neighboring epithe- 
lium, which, as we shall soon see, takes no part in the changes of preg- 
nancy. Even though YTebster describes and sIioavs the same changes 
in them as occur in the uterine epithelium. I take it for granted that 
in this case an unusual condition was present. In general Ave must con- 
sider that such a stratification of the mucous membrane does not occur. 
but that, although the change of the tubal lining into 'a basal decidua 
is present, it is not so complete as in the uterus. Concerning the char- 
acter of the epithelium at the point of insertion of the ovum opinions 
differ. According to my investigations the same changes occur here as 
in the placental area in the uterus. 

The epithelium becomes flat, disappears entirely in places and is re- 
placed by the proliferating endothelium of the maternal blood vessels. 
This extends upon the ^dlli and probably forms their syncytial covering, 
and at the same time the inner lining of the inter^dllous spaces. The 
adherent yilli pass directly into the tubal decidua, are surrounded by 
the decidua cells, and thus form an intimate connection between the fetal 
and maternal organisms. At the same time, proof is here furnished 
that the entrance of villi into glands is not essential for the development 
of an ovum. 

(/^) Decidua A'era of tlie Tube. 

In the region of the fetal sac a decidua vera is doubtless formed at the 
beginning. It is liable to certain fluctuations in size. As a rule, only 
a small annular hand around tlie lumen or only a part of ilie mucous 
memhrane of one side undergoes decidual changes. The degree of 



120 DECIDUA CAPSULARIS TUBAE. 

development of the decidua also shows individual fluctuations. Of 
course, all these conditions are confined to the early stages of pregnancy, 
so that it must first be settled whether the same stages were under ex- 
amination by the various authorities who have found differences; for 
with the further growth of the ovum such a pressure is exerted that 
after a very short time many of the details described above can no 
longer be recognized. The structure of the decidua is the same as that 
of the basal decidua, so far as the decidua cells are concerned. In no 
case could I find a spongy layer. The epithelium is somewhat flattened 
by the pressure of the ovum, and no cilia appear to be present. 

(X) Decidua Capsularis of tlie Tube (Keflexa)' 

If many differences of opinion concerning the presence and the 
extent of the decidua exist, this is to a still greater degree the case 
concerning the capsular decidua. Most authors absolutely deny its exist- 
ence. According to most recent investigations, I must take it for granted 
that only at the very earliest period can a capsular decidua he present. 
It disappears at a very early time, which explains the differences 
of opinion. In the capsular decidua the decidua cells described above are 
also, present, but between the cells there is much more intercellular sub- 
stance than between the cells of the basal decidua. According to Web- 
ster, there is present a profusion of vessels, especially in the region of 
its transition into basal decidua. At times small arteries and veins are 
near the base and at the pole, forming capillary spaces (Eugen 
Frankel). On the outer surface there are found in spots remnants 
of the original epithelium which lines the tubal membrane; these are 
cubical or flat or are in a stage of degeneration. The greater part of 
the outer surface shows complete degeneration of the epithelium. 

(d) The Tuhal ^Yall in the Region of the Fetal Sac. 

The changes affect essentially the muscle. It is very important to 
distinguish the different stages. At the earliest period there is certainly 
an hypertrophy and hyperplasia of the various elements, and the muscle 
cells increase in size as in the uterus. Very soon, however, the pres- 
sure of the growing ovum causes an atrophy of the muscle with simul- 
taneous growth of the connective tissue. In the region where the pla- 
centa becomes adherent this hypertrophy of the muscle persists the 
longest, while on the side opposite the insertion of the ovum a very 
early thinning of the wall takes place. 

(e) Chorionic Villi. 

To prove the presence of a tubal pregnancy it is necessary here, 
just as in the uterus, to show the presence of chorionic villi, i.e., struc- 
tures belonging to the fetal organism. Frequently, in an operation for 
tubal gestation, neither fetus nor placenta is found in the tube, but 
there is an extravasation of blood which dilates the cavity and is firmly 



TUBAL GESTATIOX. 



121 



adherent to one part of the wall. In sucli a case the presence of the 
deeidua cells in the tubal mucous membrane is not enough to prove 
that a pregnancy in the tube had occurred. By thorough examination 
of the blood coagulum, after pre^dous hardening of the entire specimen, 
we almost always find at the adherent portion of the coagulum char- 
acteristic chorionic villi. 

(f) The Portion of the TiChe at a Distance from the Fetal Sac, and the 

Tithe of the Other Side. 

Outside the limits of the fetal sac I was unable to find changes in 
any part of the tube on the pregnant side which could be considered as 





-4i \ 



^ 




'X^^V 



-:• / 







FiGUEE 42. SeCTIOX THEOrGH THE AEEA OF INSERTION OF THE OTCil IN A GEAVID TUBE^ 

WHICH AT a INCLUDES A POETION OF THE TUBE WITH NORMAL FOLDS 
WHICH LAY OUTSIDE THE FETAL SAC. 

a, transverse section through normal tubal mucous membrane— the folds are covered 
-with epithelium : b. chorionic villi ; c, deeidua ; cl, blood coagula. 

dependent upon pregnancy. The same is to be said of the tube of the 
non-pregnant side. 

(gj The Results of Tuhcd Gestation. 

. It is known that ova which undergo development in the tube may 
ffrow to full term and are therefore ^-lable. Such observations are be- 



122 RESULTS OF TUBAL GESTATION. 

coming constantly rarer since we have learned to regard the presence 
of a tnbal gestation in the same light as a malignant neoplasm and 
have learned to operate as soon as possible. 

In most cases there is an early interruption o£ the pregnancy, which 
may take place in various ways. Every snch accidental interruption 
is connected with danger to life. It frequently happens that the tubal 
wall cannot resist the pressure of the growing ovum and ruptures. The 
ovum, i.e., the fetus, enters the abdominal cavity and decided bleed- 
ing takes place from the placental area and the tubal wall. This blood 
becomes encapsulated and forms an hematocele, or a continued internal 
hemorrhage takes place. Rupture usually takes place in the early 
months. 

Just as in intrauterine pregnancy the whole ovum may be expelled 
through the cervix, so here the entire ovum may be expelled through the 
fimbriated end into the abdominal cavity (tubal abortion). This 
termination may be attended by the same dangers as rupture, but as 
a rule it is less dangerous. 

Through hemorrhage into the sac destruction of the ovum and re- 
sorption of the embryo may result. We then have an hematosalpinx, 
which under some circumstances may lead to secondary hemorrhage. 

Finally, I would mention that after tubal abortion retained placenta 
and decidua may form the same sort of placental polyps as in the uterus, 
and these may cause continually recurring bleedings into the abdominal 
ca\dtv. I have endeavored in the above review to give a brief 
description of the anatomy of tubal gestation. To those who are in- 
terested in the details of this important affection I recommend the work 
of J. Clarence Webster. 

(C) DiSTURBAXCES OF CIRCULATION. 

As a result of the rich supply of blood vessels in the tube, especially 
at the abdominal end, and as a result of their being embedded in a very 
loose cellular tissue, effusion of blood may follow the rupture of these 
vessels when they are strongly distended. This is the case to a very 
slight degree in menstrual congestion, as we have already said, but it 
happens that in congenital (gynatresia) or acquired closure of the 
tubes and the uterus the extravasated blood cannot flow off or be com- 
pletely absorbed, so that by the continuation of this condition the canal 
of the tube is filled more and more with blood. Then the tube changes 
to a cyst filled with blood', which at times may reach a great size. 

This condition is called hematosalpinx. This may result from in- 
juries which the patient has suffered during menstruation, a fact as 
yet only slightly regarded. I have seen a young girl, Avho was thrown 
from a horse during menstruation, showing in the next few days a 
swelling of one tube of the size of a fist with symptoms of collapse. 



HEMATOSALPINX, 123 

The danger that such tubes, turgid Avith blood, may rupture and lead 
to hemorrhage into the abdominal cavity is relatively great, because of 
the anatomical changes caused in the tubal lining and muscle by such 
effusions of blood. 

The hemorrhages into the mucous membrane lead to destruction of 
the stroma of the mucosa and the epithelium. Destruction of the muscle 
results from pressure of the constantly increasing blood clots, so that in 
extreme cases only a thin membrane separates the blood from the ab- 
dominal ca^dty. This, however, is not, as in the thick walls of ovarian 
cysts, made up of firm connective and elastic tissue, but consists of a 
membrane in which few elements can be recognized. The cells have been 
for the greater part destroyed. 



c 





i'--^^ 


-^ 


■T ' ' ' --- ' -: 


.*■■>:.'■ 




^'-<^- 


- V- 



.«4?^^"^::'^'% 10'^:'' •■"■"' 



^: 




^.siS; • . - ' - -■• 

FiGL'EE 43. — Fimbria with Hypeeemia and Lymphatic CoisGestion. 

a, turgid blood yessel ; 1), strongly dilated lymph vessels filled with lymph, which at 
d extend up to the epithelium (c). 

So long as there are only partial hemorrhages into the mucous mem- 
brane and muscle, as is the case in acute infectious diseases, poisoning, 
and acute inflammations, a restitution may take place. If, however, a 
large portion of the mucous lining and muscle is destroyed by the effu- 
sion of blood, then a restoration to the original condition is impossible. 
The most favorable result then is that the blood coagulum may become 
fully organized into connective tissue. 

For the sake of completeness I should like to add that such bleedings 
into the tube have been observed in cardiac affections. An hematosalpinx 
may occur secondarily through hemorrhage into a tubal sac which is 
filled with serous or purulent fluid. Such a hemorrhagic fluid is also 
found in malignant neoplasms of the tube. "With congestion of the 



124 TUBAL INFLAMMATION. 

blood vessels there may occur, at the same time, congestion of the lymph 
vessels. Fig. 43, which shows these conditions very clearly, is taken 
from a case suffering from carcinoma of the vaginal portion of the 
cervix. The adnexa of both sides were removed with the uterus. In 
fimbriae of both the vessels were turgid with blood and the lymph ves- 
sels exceedingly dilated, lymph having in part entered into the tissue. 
As a cause for this condition the sudden interruption of circulation by 
ligation of the vessels must be accepted. At the same time, this case 
furnishes proof of the sensitive manner in which the vessels react to 
trauma. 

(d) Inflammation. 

(oc) General Remarks. 

Before considering the anatomical changes occurring in inflam- 
mations of the tubes it is advisable to discuss the nomenclature of these 
affections. Recently every one who has worked in this field has felt i1 
his duty to invent a new name, and we find among others pyosalpinx, 
tubal sacs, tubal tumors, etc. One would imagine that every author 
wished to distinguish some point by his title; but this is not the case, 
for all these names denote the same macroscopical condition. I empha- 
size the word macroscopical. All these names seek only the characteriza- 
tion of what is found on bimanual examination. It is, however, impos- 
sible, or almost impossible, to draw from the clinical examination a 
definite conclusion as to anatomical character of an individual case. 
Very different causes and pathological processes lead in tubal affec- 
tions to the same clinical condition, and even if we see the tumor after 
operation it is often difiicult to decide by simple inspection which special 
form of the affection is concerned. This is, then, the work of the finer 
microscopical examination. For that reason it would be of general in- 
terest if a uniform expression for this condition were selected. The 
title "sactosalpinx, " used by Martin in his text book, is just as good, and 
just as bad, as the name "tubal sac," for at times we feel a decided 
swelling of the tubes without their necessarily possessing any contents. 
As a result of chronic inflammation thickenings of the wall result, even 
greater than the thickness of a thumb. These may make the canal nar- 
rower than under normal conditions, and there is then no increase in its 
contents. For such a condition the above name is not suitable. I sug- 
gest, therefore, for swellings of the tubes observed clinically the simple 
expression, "tubal tumor," i.e., a swelling of the tube. If the ovary 
cannot be isolated we have a tubo-ovarian tumor. Further classification 
is left to the microscopical examination. 

Almost the same conditions are found in the accepted microscopical 
names. So many divisions and subdivisions have been artificially made 



SALPINGITIS CATARRHALIS. 125 

that a specimen, if we follow such a scheme, often belongs in several 
categories. For this reason I suggest the simple division into 

CATARRHAL SALPINGITIS AND PURULENT SALPINGITIS 

with their resulting conditions, which we are to discuss directly. The 
attempt to divide inflammations according to the causal element is 
impracticable and incorrect ; for various causes, especially the bacterial, 
lead in the end to the same anatomical condition, from which it is im- 
possible to say with certainty whether the bacterium coli, streptococcus, 
or pneumococcus, etc., has caused the affection. 

If, as in the uterus, the inflammation of the mucous lining claims 
our special attention, we must not neglect the tubal wall and the serous 
covering; for it is not unconmion that the mucous membrane is sec- 
ondarily affected, and that the infectious process makes its way from 
without inward. Especially must we remember that adhesions with 
the tubes may very easily result from affections of the serous covering of 
the uterus (perimetritis). Through the perisalpingitic strands resulting 
from these there occur torsions and displacements of these organs, and 
in this way the basis for the occurrence of an inflammation of the 
mucous membrane is furnished. The next result of an inflammation 
of the mucous membrane is usually swelling of the folds, and hyper- 
emia, which first occurs in the numerous blood vessels of the abdominal 
end of the tube, causes serous exudation which leads to adhesions of the 
abdominal opening and may result in complete closure. The same holds 
good for the uterine opening, but here, as a rule, closure occurs later. 
By the forcible stretching which the tube undergoes in the course of 
such an affection, the entrance to the uterus is mechanically so nar- 
rowed that even in the absence of real adhesions the exit of fluid is im- 
possible. 

After these general remarks we turn our attention to the two 
forms of inflammation with their anatomical peculiarities and the re- 
sulting conditions. 

(ft) Salpingitis Catarrlialis. 

In catarrhal inflammation we may distinguish an acute and a chronic 
stage. The cause of the purely catarrhal inflammations is to be sought, 
in the first place, in mechanical disturbances. These may arise from 
needless manipulations of the uterus, as in operations, massage, and 
venereal excesses. This explains the inflammation resulting from the 
severe congestion which takes place in the genitalia during coitus. It 
has also been observed that, as a result of medicaynental injections into 
the uterus, fluid has entered the tubes and caused inflammation, the 
result of this irritation. In existing endometritis, with growth of the 
mucous membrane, an obstruction to the uterine ostium of the tube 
may occur. Since there is usually hyperemia of the other genitalia in 



126 SALPINGITIS CATARRH ALIS. 

inflammation of the uterus, there occurs in such cases a secretion in the 
tubal canal and a stasis of this secretion. 

Whatever may be the cause of acute inflammation, the evidences are 
the same as in other organs. As a result of hyperemia we find the 
numerous round cells in the tissue, so that its normal elements are com- 
pletely overwhelmed by the round cells. The result is a swelling of the 
folds in the tubal lining, which lie close together and easily become ad- 
herent. The epithelium of the surface is usually intact, but we seo 
the round cells forcing their way through the epithelium at many 
points and lying in the canal, which is narrowed by the swelling. 




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Figure 44. — Swollen Folds of Tubal Mucosa with Decided Round-Celled Infiltra- 
tion WHICH IN PART EXTENDS INTO THE MuSCLE. THE EPITHELIUM IS INTACT. 

The process does not usually extend deeper. Now and then we see 
strands of round cells following the vessels in the muscularis. As a rule, 
the hyperemia affects the serous covering, and the peritoneum looks very 
red and swollen, and shows numerous signs of inflammation, leading 
to the formation of fine membranes. In this way long-standing inflam- 
mation leads to adhesion of the tubes to neighboring organs. 

In the same way adhesions of the various parts of the tube with 
each other are formed, so that we find twistings and turnings of the tubal 



SALPINGITIS PURULENTA. 127 

canal. In long-continued cases the catarrhal inflamraation causes a firm 
closing of the addominal opening, because the swelling pnshes the fimbriae 
close to each other, causing finally a mutual adhesion. Then begins the 
chronic stage, for the tube, closed at both ends, gives no outlet to the 
secretion resulting from the hyperemia, which constantly collects in 
the tube and which may grow to very large size. I have frequently ob- 
served cases in which the tubal tumor reached up to the umbilicus. 
First the mucous membrane and then the muscle becomes atrophic from 
the pressure of the growing tumor, and it is certainly on account of 
the presence of numerous elastic fibres in the tubal wall that such swell- 
ings can exist for a certain period without bursting. At times it hap 
pens that such tubal tumors filled with serous fluid, when they reach a 
decided size, empty through the uterus, only to fill again in a short time. 
Landau, following the analogy of the conditions observed in the kidneys, 
has named this condition intermittent hydrosalpinx. The fact that the 
contents are always serous is characteristic of this process, but rupture 
of vessels occasionally occurs and the serous contents are mixed with 
blood. Another characteristic of hydrosalpinx is that in a short time the 
entire tube may become affected, so that we are dealing with a large 
cyst which may be fully emptied by puncture or incision at one point. 
Hydrosalpinx is usually one-sided, but bilateral affections are not rare. 
Through the invasion of pyogenic bacteria, either from the intes- 
tines or from the uterus, a hydrosalpinx may become a tubal abscess, but 
it seems, from my observations, that this is a rare occurrence. Purulent 
inflammations usually develop as such from the beginning, and cause 
essentially different pathological conditions from those resulting from 
the simple catarrhal form. 

(X) Salpingitis Piiriilenta, 

The purulent inflammation is the kind most frequently observed, 
especially the chronic form. An acute purulent tubal inflammation can 
usually be examined only in the cadaver, since these cases, as a rule, 
are not operated upon. We tvait until the acute process has run its 
course before we operate, and we attempt the various conservative thera- 
peutic procedures before we remove an organ of such value to the 
organism. 

There is a greater tendency for this purulent inflammation to become 
chronic than to heal completely. The anatomical changes which we are 
now to discuss are found in cases, which have come to operation after 
existing many years. This is the difference between this form of in- 
flammation and the catarrhal, for in the latter there is usually a resti- 
tution, i.e., healing. It is relatively rare that the catarrhal form 
changes into the purulent, yet such cases occur, especially if an infec- 
tion be added to an existing catarrh. The cause of a purulent inflamma- 



128 



SALPINGITIS PURULENTA. 



tion is exclusively hacterial infection. The septic and gonorrheal forms 
are the most frequent. In comparison with these, infections due to 
other bacteria are relatively rare. Among them may be considered the 
pneumococcus (Frankel) and the bacterium coli. 

Septic inflammations are mostly puerperal, yet they may occur 
through infection during operations upon the uterus, or through propa- 
gation of a bacterial affection of the abdominal cavity, such as peri- 
typhlitis, etc. At times in gonorrheal affections a mixed infection may 
occur. 




FiGUKE 45. — Chronic Salpingitis with Epithelial Involutions simulating 
Glands (a). 

h, tubal canal partly filled with pus. 



The acute stage differs very little in its early period from that 
of catarrhal inflammation. The formation of pus occurs early, so that 
the tubal contents consist no longer of serous fluid, but of purulent 
secretion. On account of the numerous cells which this pus contains 
we usually are dealing with a thick, tenacious, and sometimes cheesy sub- 
stance. In acute cases it is possible to distinguish the two main forms 
of inflammation by finding either gonococci or streptococci. If this is 
not the case we recognize the septic inflammation, as a rule, by the 
fact that it quickly makes its way deeper down, and numerous round 
cells are found in the muscle and under the peritoneum, while the gon- 



SALPINGITIS PURULENTA. 



129 



orrheal inflammation remains confined to the mucous membrane. This 
statement, to which Martin and Orthmann call attention, I have al- 
ways been able to confirm in my specimens. 

In purulent inflammation there is a marked infiltration of the mucous 
membrane with round cells and a coexisting hyperemia of the vessels. 
The folds swell and become adherent or are united by the pus found 
between them. The cilia of the epithelia disappear, but I should like to 
call attention to the fact that, in spite of long-continued suppuration, the 
epithelium of the tubal lining is usually preserved, even on the sur- 



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i»^ 






■»i"--'" 






FiGUEE 46. — Chronic Purulent Salpingitis. 
Section through the fold adhesions, more highly magnified than in Fig. 45. 



face, Avhich is certainly in contact with the pus, and we find only here 
and there certain areas denuded of epithelium. 

If the acute stage has gone over into a chronic one these adhesions 
and unions of the folds become constantly firmer and furnish remark- 
able pictures, for sections of epithelial spaces result which look like 
glands. These pictures are naturally the more complicated and the 
more difficult to judge the larger the number of folds originally pres- 
ent, especially in the ampullar end. 

In careful examination of such a specimen it may be found that 
the gland-like formations are always on the surface of the mucous mem- 
Ijrane and never penetrate into the muscularis. If they do, we have no 
y 



130 



SALPINGITIS PURULENTA. 



longer a simple inflammation, but a neoplasm. This will be discussed 
later on. If we examine sections through these fold constrictions with a 
high power, we see that they show most varying forms, which their 
origin easily explains. 

According as the folds have lain more or less close to each other, the 
sections through the spaces lined with tubal epithelium are either very 
narrow or wide. Through the marked accumulation of pus, the section 
gives us the impression that we are dealing with a cyst formation. If 
the section is oblique we may see curiously branching canals. If only the 
tops of the epithelial cells are cut it seems as though we were dealing 
with atypical epithelial growths. 



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Figure 47. — Chronic Purulent Salpingitis (hyperplastic). 

a, thickened and united folds of mucous membrane ; 6^ pus between the folds 
celled infiltration of the upper layer of the mucous membrane. 



Cj small- 



As a rule, the changes are simpler the more simple were the original 
normal conditions in the tube. Nevertheless the entire picture is in 
general the same. It must be mentioned here that the chronic purulent 
inflammations cause entirely different conditions from the catarrhal 
form, for in the latter a large tube sac is formed after a time in which 
the entire tube is uniformly affected; in the former this is not the rule. 
In purulent inflammation the tuhe is divided into different abscess 
cavities by adhesion of the various parts, so that in longitudinal sec- 
tion through the whole tube we see several cavities of different sizes 
completely separated from each other. This is the reason why such a 
<3hronic purulent salpingitis cannot be healed by simple puncture or in- 
cision. This could only be accomplished if a single tube abscess were 
present; such as happens occasionally. More of this later on. 

The anatomical changes which the tubal lining undergoes in a chronic 



SALPINGITIS PURULENTA. 131 

inflammation are, mutatis mutandis, the same as in every other chronic 
inflammation in any other organ. Through the continued irritation 
hyperplastic formations may result which affect chiefly the mucous mem- 
brane. Then we see the thickened folds lying close to each other and 
filling the tubal canal. The stroma of the mucous membrane consists 
partly of round cells and partly of granulation tissue, and the vessels 
are increased. In the narrow spaces between the folds pus is seen, which 
consists of closely gathered round cells, bacteria, and often also red blood 
cells. We are dealing, therefore, with a productive inflammation. 

With the exception of the cilia, the epithelium remains intact in the 
chronic forms for an astonishingly long time, and in the deeper folds 

j - ^ ■ , ', **%&,, 

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Figure 48. — Chronic Purulent Salpingitis. 

Marked round-celled infiltration of the folds. Superficial epithelium absent in many 
areas. 

even the cilia are not infrequently preserved. At times cases are ob- 
served in which large areas of the surface are robbed of their epithelium 
without my being able to find a plausible reason for this circumstance. 

Just as an hypertrophy of the folds may result, so an atrophy of the 
folds and the mucous membrane may be found in a long-existing case, 
especially if new quantities of pus are constantly being produced. 

This happens either through mechanical pressure exerted by the 
accumulation of pus or through direct purulent degeneration of the 
tissue. In these cases we see, as in Fig. 49, in place of the numerous 
folds, the cavity taken up by the pus, between which isolated epithelial 
areas represent the remnants of the folds. Toward the tube wall also 
there is very little of the real structure of the mucous membrane to be 



132 SALPINGITIS PURULENTA. 

recognized, and we can understand from this figure the origin of one 
of the results of a chronic inflammation, i.e., the formation of a tube 
abscess. 

The tubal wall in chronic inflammation is almost always affected. In 
most cases there is hypertrophy of the wall, and we see the round-celled 
infiltration filling the interstices of the muscularis, and also see large cir- 
cumscribed groups of round cells which resemble lymphomata. The 
vessels, even up to the peritoneum, are often seen in sections surrounded 
by a thick circle of round cells. 





C 



a- 





FiGURE 49. — Cheonic Purulent Salpingitis with Atkophy of the Folds (Atrophic). 

a, pus in the tubal canal ; 1), remains of folds ; c, large collection of pus in the tube 
wall. 

This grouping of round cells in the transition to the chronic stage 
leads either to the formation of connective tissue, or there is a degenera- 
tion of certain parts with the resulting formation of multiple abscesses 
in the wall. In either case the muscle is gradually destroyed. The only 
difference is that in the latter case there is a greater fragility of the 
wall and in the former it is consolidated. In this way we are led di- 
rectly to the results which chronic inflammation may cause. 

If the tendency of the process is toward purulent degeneration we 
find a tiibal abscess. 

The folds disappear more and more, and through purulent destruc- 
tion of the wall it becomes decidedly thinned, and perhaps before this 
the existing septa between the individual sections of the tube are de- 



SALPINGITIS PURULENTA. 



133 



stroyed and there results a genuine tubal abscess after the abdominal 
and uterine ostia are closed. 

How long the epithelium can be retained in such a solitary abscess, 
in which the pressure of the fluid accumulation is considerable, may be 
seen in Fig. 51. In this case a tubal abscess almost the size of a fist 
was present. 

The second result of a chronic inflammation is the formation of new 
connective tissue. In such a case the wall always becomes thicker 
and shows a firm consistence as the result of the connective tissue. 
The folds become atrophic, the mucous membrance has a stroma of firm 





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a 



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FiGUEE 50. — Cheonic Pueulent Salpingitis ; Round-celled Infilteation in the Tube 

Wall (meso- or my o salpingitis). 

a, muscle of the tube wall ; 1), small-celled infiltration ; a, round and outlined area of 
infiltration. 



connective tissue, the epithelium may disappear, and there may even re- 
sult the firm closure of the tubal canal. Such a tube may be thicker 
than a thumb, and, if no new injuries through adhesion with the ab- 
dominal organs take place, may cause the patient no annoyance. 

In describing the various anatomical changes which chronic purulent 
tubal inflammation causes, I have avoided giving a special name to the 
individual forms. 

I should consider it of advantage if others would accept this plan, for 
all the various titles only cause confusion. In my opinion it is unneces- 
sary, when the above-mentioned formation of adhesions between the 



134 



SALPINGITIS PURULENTA. 



folds simulates glands, to name this microscopical condition salpingitis 
foUicularis, or, what is better, pseudofollicularis. In addition, we hear 
of salpingitis isthmica nodosa, chronica productiva vegetans, intersti- 
tialis disseminata, parenchymatosa chronica, a pachysalpingitis — names 
which are understood after the above-mentioned description, but which 
should be considered as unnecessary ballast and thrown overboard. . 
In the former description we have spoken of and observed only the 
tubes. As we have often mentioned, however, there occur very early 
in inflammatory changes adhesions of the tube to neighboring struc- 
tures, especially to the ovaries, and in this way formations gradually 
arise where we cannot decide whether we are dealing with the tube alone 
or mth the tube and ovary. We call such formations 





< <- 









f ! 







FiGUKE 51. — Tubal Abscess. 
a, pus ; tj, very thin tube wall, with an almost even epithelial lining of the interior ; o, 
remaining and atrophic folds. 

(•^) Tubo-ovarian Tumors. 



The inflammatory processes which occur on the serous covering of the 
tubes and ovaries lead to the formation of delicate, transparent peri- 
toneal adhesions. These occur either as flat or band-like formations. 

Usually there occurs at first a union of the fimbriated end with the 
ovary, the still open fimbriae adhering to a corpus luteum and uniting 
with it, or else the already closed fimbriated extremity is constantly 
drawn by adhesions closer to the ovary. We often have occasion to 
operate upon these cases in such a stage in which the ovary can he 



TUBO-OVARIAN TUMORS. 



135 



plainly distinguislied from the tuhe and where the ovary sits upon 
the tnbe like a fungus. 

We see the membranes gradually extending from all parts of the 
tube to the ovary, so that mth its entire surface it is drawn over to the 



c 



/T^^ 



f - 




a 







FiGUKE 52. — Adhesion between Tube and Otaet. 
a, tube ; 6^ transparent membranes between tube and ovary (cj. 

tube in its entire extent. Both organs may be recognized through the 
delicate transparent membrane. 

In the further course, the adhesion is always closer, and out of the 
delicate transparent membranes are formed firm connective-tissue bands 








c d 

Figure 53. 
Qj tubo-ovarian tumor seen externally; J), longitudinal sections through the same (T. 
tubal twistings ; O, ovary); c and d, longitudinal section through another tubo-ovarian 
tumor, cut surface opened (T, sections through the twisting tubal canal; O, ovary) ; Ca, 
corpus albicans ; F, closed and retracted fimbriated end. 



which cause it to appear as if both organs were one mass, and we then 
call this condition a tubo-ovarian tumor. Such a tumor is usually united 



136 



TUBO-OVARIAN TUMORS. 



to the posterior surface of the uterus by adhesions, so that in examining 
we are often unable to clearly define it from the uterus. 

The union of both organs does not remain, however, only superficial, 
so that they may be isolated after the division of the firm membranes, 
but, through union of the elements composing these two organs, there 
may result actually a single tumor. This may be recognized in longi- 
tudinal sections made through the entire tumor, as seen in Fig. 53. 

A microscopical section through the uniting membrane makes this 
condition still more distinct. Even by magnification with an ordinary 
lens (Fig. 54) it may be seen that we are dealing with a uniform forma- 
tion. In the early stages we recognize the boundary between the tube 
and the ovary by a zone of small-celled infiltration. If the process is 







Figure 54. — Tubo-ovarian Tumoe. 

a, section tlirough the ampulla of the tube ; 1), tube wall ; c, ovarian tissue ; d, small 
cysts ; e, transition of the tube wall to ovary. 



more advanced both tissues run into each other by means of a firm 
connective-tissue union. In this way all further changes which such 
tubo-ovarian tumors undergo can be easily explained. 

If after chronic purulent salpingitis a tubal abscess results, the pus 
may break through into the ovary and cause a coexisting ovarian ab- 
scess. Even though no complete abscess is present, but only isolated pus 
■formations in the various parts of the tube, the union of both organs 
may lead to the penetration of pus into the ovary and the formation of 
an abscess. Gradually then one large abscess develops. It may happen 
that the tube goes directly into a corpus luteum, and then a corpus 
luteum abscess may be formed. 



INFECTIOUS GRANULOMA. 137 

When the tubal affection results in healing, both organs are still more 
firmly united, the structures of both are replaced by connective tissue, 
and the organs lose their function. It is not my purpose to discuss the 
union of the affected tubes with other organs, but I should like to men- 
tion that a not infrequent adhesion is that with the vermiform ap- 
pendix. The origin of appendicitis from affections of the uterine adnexa 
is a fact which, in my opinion, has not as yet attracted sufficient atten- 
tion, even though slight attention has recently been called to this fact. 

Finally, it happens that the fimbriated ends of both tubes unite with 
each other. 

(e) Infectious Granuloma. 

Under this heading we must include actinomycosis in addition to 
tuberculosis and syphilis. The former is very rare and usually propa- 
gated from other organs. In the pus we find the typical form of the star- 
shaped fungus. The microscopical changes in syphilis possess no de- 
cided criteria so long as we do not know its cause. The few affections 
observed in syphilis, so far as the tube is concerned, show a chronic 
productive inflammation. 

In tuberculosis of the tube tubercles form first in the mucous lining 
and then in the other parts of the wall. At times tubercle bacilli are 
found in the giant cells, but it is difficult to find them in every case. 

The pus formed in this affection is thick and contains cheesy masses. 
The dilatation of the tubes may be very great. It is remarkable that 
tuberculosis develops primarily in the tubes relatively often. In con- 
junction with tuberculosis there may occur the well-known '' atypical 
epithelial growths" of Friedlander, which usually remain confined to 
the mucous membrane, but which may also penetrate the superficial lay- 
ers of the muscle. 

(f) Hypertrophies and Hyperplasias. 

Fluctuations in the size of the tubes are very frequent, so that in 
describing the normal condition we must usually allow a rather wide 
field of variation. In inflammatory affections there may result decided 
elongation and thickening of the tube. These may be either one-sided or 
bilateral. Recently I observed in a double-sided pyosalpinx that the 
length of the tube from the uterus to its abdominal end was sixteen 
centimetres. The elongations in myoma of the uterus are still more 
considerable. In one case operated upon by me the interstitial portion 
of the tube was twenty-three centimetres long. 

The partial hyperplasias lead, as a rule, to the formation of polyps 
of the mucous membrane. These extend into the canal of the tube and 
may, in some cases, completely close it. We have already discussed such 
polyps as a cause of the occurrence of tubal gestation. Their micro- 



138 HYPERTROPHIES AND HYPERPLASIAS. 

scopical structure shows nothing remarkable. In the polyps the ele- 
ments of the matrix are reproduced. The vessels are usually increased. 
Isolated hyperplasia of the epithelium may occur, in which the stroma 
of the mucous membrane takes part only as a supporting substance. 
This causes villous formations such as occur in all hollow organs, and 
on account of their macroscopical appearance are called papillomata 
(bladder, intestine, ovarian cysts). These are always confined to the 
mucous membrane. 











i ■fa- '- ' ,- -- ' v.--^ 



_Ar*-rXV— *•**■ '^•'^ ^ 



V 







~^: 



\ . 



:\ 



Figure 55. — Caecinoma of the Tube. 
a, carcinomatous bands on the surface of the mucous membrane ; h, muscle ; o, carcino- 
matous masses with an alveolar structure, penetrating deeply into the muscularis. 



(g) Neoplasms. 

As compared with carcinoma, the other new formations are much 
rarer. Even the carcinomata occur only here and there as primary 
tumors. They originate, according to our present observations, from 
the epithelium of the mucous membrane and form epithelial growths 
of a villous structure. The epithelial strands lie without interstitial 



TUBAL NEOPLASMS. 139 

substance, often in irregular groups next to each other, and penetrate 
the tube wall, whose elements they destroy. This is another characteristic 
favoring the diagnosis carcinoma. If such epithelial growths are lim- 
ited to the mucous membrane alone, without showing that characteristic 
alveolar structure of a carcinoma with which we connect the clinical 
understanding of malignancy, it lies beyond our power to say with cer- 
tainty from a microscopical picture whether in such a case we are deal- 
ing with a malignant process or not. 

Carcinomata with the typical alveolar structure also occur in the 
tubal wall and the tube lining. The name "papillary carcinoma" of 
the mucous membrane for changes which do not possess destructive 
characteristics seems to me to be unfortunately chosen. 

I should like to mention that after extrauterine pregnancy a tumor 
in the tube with destructive tendencies has been described (chorioma). 

Barer than carcinoma is sarcoma of the tube. The majority are 
round-celled sarcomata. 

The benign neoplasms of the tubal wall (myoma, fibroma) occur 
rarely and show no microscopical peculiarities. 



VI. THE OVARIES. 

1. NORiMAL ANATOMY. 
(a) Position and External Form. 

Concerning the normal position of the ovary various opinions ex- 
isted until recently. After a series of examinations which Hammer- 
schlag made in the Berlin Anatomical Institute under the direction of 
Waldeyer, that position which Waldeyer long ago described has been 
found to be the normal. We therefore follow the description given by 
Hammerschlag. 

The ovary has a flattened cylindrical form with a convex surface 
toward the abdominal cavity and a slight concave surface toward the 
tube. After puberty its length is about 2.5-5 cm., its width is 2 to 3 
cm., and its thickness is 1 to 2 cm. Its long axis is almost parallel to that 
of the body. 

The ovary is suspended between the suspensory ligament of the 
ovary (running to the cecum and the vermiform appendix on the right 
side and to the sigmoid flexure of the colon on the left) and the ovarian 
ligament (running to the uterus). At its hilus it is fastened to the mes- 
ovarium, a fold from the posterior layer of the broad ligament. The 
hilus edge of the ovary looks forAvard and outward, the convex edge 
backward and inward. The wall surface lies close to the lateral wall 
of the pelvis; the free surface looks toward the pelvic interior and is 



140 " ANATOMY OF THE OVARY. 

covered by the tube and the mesosalpinx. At the places in which the 
ovary lies during the different periods of age it causes more or less 
deep impressions in the pelvic wall, i.e., in the peritoneal sac. Between 
the branches of the hypogastric artery may be considered its typical 
final position. 

Here the ovary lies in a groove caused by its own configuration, the 
fossa ovarica, whose normal boundaries are anteriorly the umbilical 
artery, the obturator nerve, and posteriorly the uterine artery and the 
ureter. "Waldeyer distinguishes on the lateral pelvic wall from before 
backward a fossa paravesicalis anterior and posterior, a fossa obturatoria, 
and a fossa hypogastrica. The ovary occupies as its special region the 
posterior portion of the fossa obturatoria. 

The ovary is united to the uterus by the ovarian ligament, which 
is attached to the posterior surface below the origin of the tube. The 
surface of the ovary is not smooth, but shows small elevations and small, 
sometimes star-shaped depressions. The elevations are caused by the 
growth of the follicles, which force their way up to the surface, while 
the depressions are caused by retraction after rupture of the follicles. 
The ovary has a semi-firm consistence and is of a grayish- white color. 



(b) Anatomical Structure. 

In the ovary we distinguish two divisions, the vascular layer and the 
parenchymatous. Unfortunately a certain confusion exists on account 
of the various names given by various investigators, thus unnecessarily 
complicating the relatively simple anatomy of the ovary. The classifica- 
tion given above is adopted from the splendid work of Waldeyer on the 
ovary and ovum, and should be generally accepted on account of its 
simplicity. "We may, however, add, as the external boundary of the 
parenchymatous, a cortical layer, the albuginea. This cannot be isolated 
by dissection, but goes gradually over into the parenchyma. 

(a) The Vascular Layer. 

Through the hilus of the ovary the vessels enter in such number 
and size that scarcely any other tissue is present between them. The 
veins in the hilus, mingled with muscle fibres, form a special corpus 
cavernosum— &it?&iis ovarii (Rouget). A transverse section through 
this part gives the impression of cavernous tissue. A remarkable cork- 
screw-like twisting characterizes the ovarian arteries. The arteries enter 
the ovary in this way and retain this peculiarity in their finer ramifica- 
tions until they divide into a capillary network. The arteries have 
strong muscular walls, the only muscle fibres which exist in the ovary. 
In addition to blood vessels, lymph vessels and nerves enter the ovary. 



OVAEIAN STROMA. 141 

(h) The Parenchymatous Layer. 

This layer gives the ovary its characteristic stamp, for it contains 
the important elements necessary for propagation, namely, the follicles 
containing the ovum. 

(oc) The Stroma. 

The stroma consists of a firm connective tissue with numerous in- 
terlacing fibres and more or less numerous spindle-shaped nucleated 
ceils. Elastic fibres are also found. The nearer we approach the sur- 
face the more does the number of nuclei diminish, so that the cortical 
layer may be said to be a fibrillary connective-tissue boundary of the 
organ. The surface is covered ^vith peritoneum at the hilus, while the 




Figure 56. — PAEEXCHYMATors Layek of the Ovaey, mith Follicles ix a State of 

Rest. 

a, stroma; 1), follicles (tlie ova are only faintly evident in a few follicles). 

part which projects freely into the abdominal cavity is covered with a 
more cubical epithelium, the so-called ''germinal epithelium," and 
contains no covering which may be called "corpus serosje." 

The germinal epithelium forms depressions in the tissue only during 
the period of development of the ovaries. These invaginations of the 
epithelium are later changed to follicles containing ova. 

(/5) The FoHicle. 

The follicles are cyst-like formations Avhich are of various size, ac- 
cording to their state of development (ripening). Their diameter varies 
between 0.04-1.5 cm. 



142 



GRAAFIAN FOLLICLE. 



The small follicles lie in several layers near the surface, the larger 
ones lie more in the deeper layers. As they grow the ripening follicles 
again approach the surface, from which they then project. 

The smaller follicles may be called 

{(X) FoUicles iu a State of Rest. 

They surround the ovum with multiple layers of cubical epithelium, 
which becomes flatter the further advanced the follicle is. Seen in sec- 
tion, strongly magnified, the external layer of the follicle epithelium is 
like the epithelium of a gland. The internal layer lies in a different 
plane and the cells are seen from above, so that they appear indistinct 
and more like squamous epithelium. In the middle of the follicle lies the 
ovum. 

The ripening of the follicle is shown by the formation of vacuoles 
in that part of the epithelium lying near the surface of the ovary. The 
resulting space, becoming continually larger, is filled with a clear fluid, 
the liquor follicidi. It contains pseudomucin. At the same time an 
increase in the vessels is observed at the periphery, as the beginning of 
a special connective-tissue cover. This stage of development, in which 
the growing egg causes an active proliferation of the epithelium of the 
follicle with formation of the follicle fluid, is given an especial name, the 
Graafian or vesicular follicle (foUiculus vesiculosus). 

1/3) The Graafian FoUicle. 

The Graafian follicle is surrounded by a connective-tissue wall (theca 
folliculi) in which we distinguish an external firm layer poor in cells and 
an internal layer rich in cells and containing vessels (tunica fibrosa and 
propria) . I would call attention to the fact that these two layers cannot 
always be distinctly outlined in the microscopical picture. 

The following follicle epithelium surrounds the liquor folliculi in 
multiple layers (memhrana granulosa) , the outermost cells being of 
cubical form, while on the inner surface they are flattened. 

At that part of the follicle where the ovum is found, generally op- 
posite the surface, there is formed a considerable grouping of epithelial 
cells of the follicle (cumidus or discus proligerus). Toward the liquor 
folliculi the ovum is marked off by a less dense, and in parts a single, 
layer of epithelium. The ovum possesses an external membrane (zona 
pellucida) . This shows a radial striation and surrounds the protoplasm 
(yolk) in which the nucleus (germinal vesicle) and the nucleolus (ger- 
minal spot) lie. 

(c) The Further Course of the Ripe Follicle. 

When the ovum has completely ripened the follicle projects in part 
above the surface of the ovary, and at a certain time bursts and dis- 



CORPUS LUTEUM. 



143 



charges the liquor foUiculi and the ovum. At that point at which this 
rupture takes place the wall is decidedly thinned. 

At the time of bursting an extravasation of blood into the cavity of 
the follicle takes place. Later certain changes in the way of prolifera- 
tion occur which lead to the formation of the so-called corpus luteum. 

These changes are quantitatively greater if pregnancy takes place 
through fecundation of the expelled ovum (corpus luteum verum) ; less 
decided if the ovum is not fecundated (corpus luteum spurium). The 
character of the change is the same in both cases. 




Figure 57. — Graafian Follicle. 

Oj theca folliculi ; 1), membrana granulosa ; c, cumulus or discus proligerus ; cl, liquor 
folliculi ; e, zona pellucida ; f, yolk ; g, nucleus ; h, nucleolus. 



(a;) The Corpus liXiteum. 

After expulsion of the ovum from the follicle the lacerated area 
unites quickly. From the wall comes active growth and formation of 
new vessels. These send branches into the membrana granulosa and 
carry to these cells new nutritious material, so that a decided enlarge- 
ment and an increase in the number of these cells results. These cells 
take on a character resembling the decidua cells, and line the wall in 
numerous overlying layers. These cells project more or less into the 
interior filled with blood, so that a ruffle-like lining is formed. 

We call these cells, which frequently contain pigment and which 



144 



CORPUS ALBICANS. 



give the corpus luteum its characteristic stamp, lutein cells. Whether 
these lutein cells originate from the follicle epithelium, or whether they 
are connective-tissue cells furnished by the theca interna, is still an 
open question. I hold to the view that they originate from the follicle 
epithelium (Sobotta). 

As a result of the pigment deposited in the lutein cells and the 
blood poured into the interior of the follicle, the latter has a yellow 
appearance, wherefore it is called ''the yellow body." After a time 









'.j^-^' '^}W 6^ 



fe 



^/-i9 

















FiGUEE 58. — Feom the Wall of- a Coepus Luteum. 
a, lutein cells ; &, spaces resulting from loss of lutein cells (artificially produced) ; c, 
lymph spaces between lutein cells ; d, capillaries with endothelium and connective tissue. 



the growth of the lutein cells ceases and the blood coagulates and is or- 
ganized, the lutein cells gradually disappear, an active production of 
connective tissue displaces them from the circumference, so that in 
this way the entire interior is filled with connective tissue and we 
have a 

{^) Corpus Albicans. 

This represents the end stage of the follicle after it has completed its 
function. This may be compared to the end stage of a chronic inflam- 



OVARY DURING MENSTRUATION. 145 

mation, leading not to restitution, but to connective-tissue formation. 
In a section through an ovary the corpora albicantia are outlined as white, 
shiny, irregularly rounded or stellar formations. Every rupture of a 
follicle leaves behind on the surface of an ovary a scarred depression. 
In this way gradually numerous depressions are formed, and between 
them prominences which occasionally resemble the convolutions on the 
surface of the brain, as I have observed in a remarkable case of this sort 
(ovarium gyratum). 

(c) The Ovary during Menstruation and Pregnancy. 

As a result of the congestion of the genitalia during menstruation 
the ovarian vessels are also filled wdth blood. As a rule, there is no 
extravasation of blood into the ovarian tissue. I cannot enter into the 
physiological relation between ovulation (the ripening and expulsion 
of the ova from the follicle) and menstruation. I should like to men- 
tion that, according to recent investigations on this subject, the opinion 
that menstruation is dependent on ovulation is becoming stronger. 

In pregnancy the ovary which expelled the fecundated egg or o\"um 
becomes larger than the ovary of the other side, through the formation 
of the corpus luteum. The other changes in the ovary in pregnancy are 
limited to an enormous enlargement of the vessels. No special changes 
in the parenchyma or epithelium of the ovary occur. It deserves no 
further mention that, of course, mth the gro^vth of the uterus during 
the progress of pregnancy the ovaries change their position and as- 
cend into the false peU^s. 

(d) Senile Atrophy of the Ovary. 

When menstruation ceases (climactermm) an increased formation of 
connective tissue results, which leads to atrophy of the follicles, to a 
thickening of the albuginea, and to a shrinking of the entire ovary. 

2. PATHOLOGICAL ANATOMY. 

(a) Ovarian Gestation. 

Even though ovarian pregnancies are of little practical importance 
compared with tubal gestations, it must be mentioned that an ovum may 
also develop on the surface of an ovary. It has been stated that the 
fibrous layers of the albuginea have been seen directly continuous ^\dth 
the fibrous covering of the fetal sac. It has also been stated that an 
ovum may develop within a follicle. 
10 



l-i6 OVAEIAX HYPEREMIA, 

(b) Disturbaxces of Circulatiox. Hypereml\. 

As in the uterus, disturbances of circulation in the ovary are gen- 
erally the result of infectious diseases. There results either bleed- 
ing into the follicle and the corpora lutea or into the interstitial tissue. 
The hemorrhages may in certain cases become so pronounced that the 
larger portion of the interstitial tissue is destroyed and a hematoma of 
the ovary residts. Through rupture of such a space filled with blood, 
hemorrhages which endanger life may occur into the free abdominal 
<?avitv. 

Among other causes which lead to such bleedings may be men- 
tioned those injuries which the individual may meet with during men- 
struation (trauma). 



a 




/ 

- / 

/ 



FiGUEE 59. — ExoEMors Htpekteopht of the Blood Vessels i>- ax Otaey i>" a Case 

OF Myoma of the L'teeus. 
a, connectiye-tissue degeneration in tlie stroma : 6, cystic formation in a follicle. 

Hyperemia with considerable new formation of vessels may be ob- 
served, aside from inflammatory infections, especially in neoplasms of 
the uterus, if these have reached a considerable size, and particularly 
in large mijomata. There results an enlargement of the entire ovary, 
its individual elements becoming hypertrophic through the increased 
supply of blood. That condition is iUustrated in Fig. 59, the section 
being taken from such an ovary associated with a very large myoma of 
the uterus. 

(C) IXFLAMMATIOX. 

The inflammations of the ovary are of so little practical importance 
as compared with neoplasms that we will confine ourselves to a dis- 
cussion of the most essential points only. 



OOPHOEITIS. 147 

(oc) Interstitial Ooplioritis. 

In the interstitial form we distinguish a chronic and an acute stage. 
The acute inflammation is chiefly caused by a septic or a gonorrheal in- 
fection, and causes a marked small-celled infiltration of the interstitial 
tissue with simultaneous hyperemia and increase of the vessels. 

Extravasation of blood into the tissue may result, and if at the same 
time there is an entrance of pyogenic bacteria, formation of pus takes 
place. The suppuration involves either the entire tissue, the pus 
changing the entire ovary into a large abscess canity (ovarian abscess) 
by breaking through the walls of the follicle, or else the suppuration is 
confined to individual parts. In this way there results not infrequently 
a suppuration of the corpora lutea and the formation of corpt's-lufeum 
abscesses. 



/ ■ ■ ,-■■■'"-■-./■ '—' 



/ 
I 

I 



a 





h-^ ^.-^. - :- -- 

V 

Figure 60. — Ixterstitial Oophoritis. 
a, section through a large vein ; 6, small-celled infiltration : c, newly-formed vessels. 

The characteristic of these abscesses is that we find in them a wall 
consisting of lutein cells. Macroscopically we see in large abscesses of 
this sort, on section, wav^j elevations of the inner wall. This form we 
have learned in discussing the normal anatomy of the corpora lutea. 

In the chronic form there results the formation of connective tissue 
with retraction. The follicles are mostlv destroved and the stroma 
shows, in place of the numerous cell elements, fibrous connective tissue. 
The epithelium of the surface is preserved longest in such a condition. 
"When this is destroved it mav, however, still be observed in the folds or 

«. t. 7 7 

sinuses which have been caused by retraction. 

I do not desire to consider as a separate division the so-called "Folli- 
cular Oophoritis,'' but refer to the chapter on small cystic degeneration. 

(fj) Periooplioritis. 

In connection with an oophoritis there frequently occurs a peri- 
oophoritis in which inflammatory deposits are formed on the surface of 



148 SMALL CYSTIC DEGENERATION. 

the ovary, leading to adhesion with neighboring organs, especially the 
tube, uterus, and intestines. Such adhesions are more frequently formed 
secondarily, as a result of tubal affections, as we have already seen. The 
adhesions lead to the formation of the tubal tumors already mentioned. 
The germinal epithelium of the surface is early destroyed by this pro- 
cess. Perioophoritis may also secondarily give rise to an oophoritis, 
f 

(d) Infectious G-ranuloma. 

The syphilitic affections of the ovary are as yet little known, so that 
we possess no positive characteristics for their microscopical deter- 
mination. 

Tuberculosis frequently occurs secondarily , but rarely primarily, in 
the ovary. As a rule, we see tubercles with giant cells in the interstitial 
tissue. At times such tubercular masses are found in the wall of the 
cysts or in the walls of a corpus luteum. The presence of tubercle bacilli 
can rarely be proven. 

(e) Parasites. 

The repeated observation of echinococci in the ovary recently leads 
me to call attention to their occurrence. The positive microscopic proof 
that the echinococcus aff'ection has taken its origin from the ovary can 
only be furnished by finding ovarian tissue in the wall of the sacs. 
Such early stages, however, have not yet been observed. Proof that we 
are dealing with an echinococcus cyst of the ovary can only be fur- 
nished, according to B. S. Schultze, by showing the characteristic posi- 
tion of an ovarian tumor in its relation to the tubes and mesosalpinx. 

(f) Small Cystic Degeneration. 

The transition from inflammatory processes in the ovary to neo- 
plasms is furnished by retention cysts. These originate, as a rule, in 
consequence of chronic inflammatory changes.- Through the resulting 
hyperemia there occurs a serous exudation from the vessels of the theca 
interna, and an effusion of serous fluid into the follicle. A portion 
of the epithelium of the follicle disappears and is replaced by fluid. 
The lining of the cyst wall consists of cuboidal epithelium. If the 
process is far advanced the greater portion of the interstitial tissue may 
be replaced by cysts. In the early stages the remaining interstitial 
tissue is infiltrated with small cells. The cysts, as a rule, attain the size 
of a ripe Clraafian follicle ; still larger ones have been observed. In the 
latter the epithelium lining the wall is destroyed by pressure of the 
fluid. The cyst fluid is usually cloudy from degeneration of the epi- 
thelial cells. It is therefore seen that in these retention cysts the epi- 



OVARIAN NEOPLASMS. 



149 



thelium plays only a passive role. The contents of these cysts, in con- 
trast to those of true neoplasms, include pseudomucin. 

(g) Neoplasms. 

By neoplasms of the ovary we understand those tumors which do not 
result from inflammatory causes, but which are the result of irritations 
whose nature we do not yet comprehend. "Whether we are dealing with 




Figure 61. — Mickocystic Degeneration of the Ovary. 

a, follicles which have undergone microcystic degeneration ; h, small-celled infiltra- 
tion ; c, corpus albicans. 



a further growth of cells dating from the embryonal period, or whether 
some form of parasite is to be considered, cannot be decided in the light 
of our present knowledge. 

The tendency to the formation of cysts is characteristic of tumors of 
the ovary. As a matter of fact, solid ovarian tumors are in the back- 
ground compared with cystic. For the classification of these growths 
in an anatomical work like this, only anatomical and genetic points of 
view are considered. 



150 EPITHELIAL NEOPLASMS. 

We therefore distinguish two main forms : those which take their 
origin from the epithelium, and those which originate from the connective 
tissue. Some authors desire to divide these epithelial neoplasms into 
groups, according as they originate from the various forms of epithelium 
found in the ovary. But this does not simplify matters. In addition 
such a division is unnecessary, since the follicle epithelium originates 
from the germinal epithelium and genetically is the same. The pres- 
ent division, found in text books, into solid and cystic tumors may be 
clinically correct, but in an anatomical description would lead to repeti- 
tions. 

1. Epithelial Neoplasms. 

{oq Stirface PapiUoma. 

Surface papillomata are rare as compared with cystic formations. 
The germinal epithelium in these growths proliferates and forms nodular 
elevations above the surface. The ovary acquires in this way an ir- 
regular appearance, and cauliflower-like formations may result from 
further growth. In this way there are formed in these elevations de- 
pressions of epithelium, such as occur in pointed condylomata, so that 
the various forms have a very irregular appearance. Connective tissue 
gradually makes its way into the originally purely epithelial elevations, 
but it is characteristic that the growth remains confined to the surface, 
and that deeper depressions of the epithelium into the ovarian stroma 
do not occur. In that way these papillomata resemble the epitheliomata 
of the other organs. 

(J3) Follicle Cysts. 

In contrast to the retention cysts due to inflammatory causes, as 
we have already learned, there may also occur genuine cystic neoplasms 
which may cause a decided enlargement of the ovary. As a rule, a 
large number of follicles undergo cystic degeneration, so that in one 
section through the ovary we obtain a picture resembling a honey- 
comb with various large cells. By union of several cyst walls and their 
subsequent disappearance, one large cyst may result. The follicle epi- 
thelium may be replaced by cylindrical cells. These line the wall and 
are preserved even when the neoplasm increases greatly in extent, and 
they continue to produce the cyst contents. The ova which are present 
in the follicles are early destroyed. Cystic degeneration may occur in 
a corpus luteum just as in a follicle, and very interesting formations 
result, to which recently attention has repeatedly been called. 

(y) Corpus-Iiuteviin Cysts. 

The proliferation of the lutein cells which takes place after the 
ovum has been expelled from the Graafian follicle, and which normally 
terminates after a certain period and then gives way to connective- 
tissue contraction, may continue, under circumstances which we do not 
yet understand, and may lead to the formation of cysts of the corpus 



CORPUS-LUTEUM CYSTS. 



151 



luteum. These, as a rule, do not attain any considerable size, so tliat 
a growth the size of a fist is rare. 

Macroscopically we can recognize the irregular w^avy surface of 
the inner wall of this cyst. In section the wall is seen to be of con- 
siderable thickness, and the wavy elevations extending toward the cyst 
interior look like those found in a corpus luteum. This alone, how- 
ever, is not sufficient for diagnosing such a cyst : microscopical ex- 
amination of the wall is absolutely necessary. 

We then see that the wall of a corpus-luteum cyst has a very char- 
acteristic structure. We distinguish three layers, an external, a middle, 
and an internal. The latter goes over with a sharp demarkation into 
the viscous yellow contents, in which no special formed elements can 
be distinguished. In stained sections these three layers may be macro- 




FiGUEE 62. — CoEPUS-LuTEr:M Cyst (enlarged three times). 

a, ovarian tissue ; 6^ external laj-er of tlie cyst ; Cj, middle layer ; d^ inner layer : e^, 
small follicle cyst. 



scopically recognized by the varying intensity of the stain. The external 
layer is most deeply stained, the middle less, and the internal layer 
scarcely at all. These cysts are usually found at one pole of the ovary. 

The external layer has a connective-tissue stroma, in which numerous 
vessels, mostly arteries and veins, run in a circular direction. Around 
the vessels at many points are seen groups of round cells. From these 
main vessels numerous branches pass in a perpendicular direction into 
the middle layer, in which they dissolve into a capillary network. The 
middle layer gives the cyst ivall its characteristic stamp, because the well- 
known large lutein cells lie between the vessels and the capillaries. They 
occupy almost the entire space between the vessels, and are only inter- 
rupted in the course of the vessels by groups of round cells, which follow 
the course of the vessels, so that occasionally only these round cells 
are seen and the underlying capillaries cannot be distinguished. The 



152 



CORPUS-LUTEUM CYSTS. 



more we approach the inner layer the less distinct is the contour of 
the lutein cells. In part they are without nuclei. The inner layer 
shows only the transition of the cellular elements of the cyst contents, 
which are undergoing regressive changes. 

The contents show large lutein cells in a state of dissolution lying 
in a delicate connective-tissue network forced apart by homogeneous 











Figure 63. — Feom the Wall of a Corpus-Luteum Cyst (highly magnified). 

a, vessels of the outer layer of tbe cyst wall ; h, lutein cells of the middle layer ; c, 
capillaries cut longitudinally ; d, grouping of round cells ; e, spaces resulting from the 
artificial removal of the lutein cells. 



fluid. At certain points are seen strands of wavy connective tissue ex- 
tending toward the cyst contents. 

The inner layer is in most cases not lined off from the cyst contents 
by epithelium, as is the case in real cystomata of the ovary. This ab- 
sence of an epithelial lining of the inner wall is considered by some 
authors to be the principal characteristic of corpus-luteum cysts. 



OVARIAN CYSTOMATA. . 153 

Eecently corpus-luteum cysts have been described in which such an 
epithelial lining was present. According to my investigation, this epi- 
thelial layer, if it is present at all, is destroyed very early. This can 
be explained by the fact that this epithelium plays only a passive role, 
and is destroyed through the pressure of the increasing fluid contents. 

The main role in the origin of these cysts is played by the lutein 
cells, which are in a stage of abnormal proliferation and degeneration. 
In this way the degenerating cells and those forming the cyst contents 
are continually regenerated. The cyst contents obtain their peculiar 
color from the pigment which the lutein cells contain. 

It may be seen from these conditions that these cysts (so far as the 
lutein cells are derived from the follicle epithelium) are justly reckoned 
with the genuine epithelial neoplasms of the ovary. It is evident, on 
the other hand, that cysts cannot be called corpus-luteum cysts simply 
because they have no epithelial lining to the wall. 

For their diagnosis it is necessary to show the presence of lutein 
cells in the middle layer of the wall. It is possible that in the later stages 
these lutein cells may be destroyed, and, after this, enlargement of the 
cyst could no longer continue. Then only the wrinkling of the wall 
would remain as a characteristic. It must be mentioned that even in 
large cysts of this sort lutein cells have been found, and that, on the 
other hand, a wrinkling of the inner wall may occur in ordinary 
cystomata. 

(jd) Cystomata or Cystadenomata of the Ovary. 

The cystomata are the most frequent form of tumor found in the 
ovary. They are either uni- or bilateral, and may reach a very enormous 
size. The cystomata, in contrast to follicle cysts, probably develop from 
displaced epithelial cells. For this reason they must be reckoned among 
the glandular neoplasms, the adenomata, whose epithelial cells are able to 
produce large quantities of fluid. It would be anatomically correct, 
therefore, to consider these tumors as cystadenomata. According as the 
inner wall is smooth or lined with polypoid growths we distinguish 
simple cystadenoma from papillary cystadenoma. 

(a) Simple Cystadenoma. 

Simple cystomata are either uni- or multilocular — i.e., they form 
either one large cystic cavity or contain in addition to onfe large main cyst 
a series of smaller accessory cysts. Through union of the various walls 
and the disappearance of the latter, a simple cyst may result from a 
multilocular. The wall is more or less thick according to the degree of 
dilatation of the cyst. The cyst wall contains a connective-tissue basis 
in which are very large blood vessels, especially veins. In parts we see 
a small-celled infiltration. In long-standing cysts the wall may contain 
much fibrillary connective tissue. 



154 OVARIAN CYSTOMATA. 

The inner wall is lined with cylindrical epithelium which continually 
produces fluid. At times the cylindrical epithelium is changed to the 
ciliated form. In spite of the dilatation of the cysts the epithelium which 
forms an essential part of them is preserved. The external surface of the 
cysts occasionally shows the presence of germinal epithelium still pre- 
served. 

The contents of the cysts consist of a somewhat sticky fluid, usually 
clear as water. At times the fluid is cloudy and may be brownish red 
from admixture of blood. The most important chemical ingredient of the 
fluid is pseudomucin. In the smaller cysts ovarian tissue is sometimes 
found in the wall. 







f 
e 



'A 




V 



Figure 64. — Sections through the Wall of a Simple Cystadenoma of the Ovary. 
a, cylindrical epitbelium lining the inner wall ; J), vessels ; c, groups of round cells ; d, 
dilated lymph vessel with colloid contents ; e, connective-tissue stroma. 

The true adenomata, consisting exclusively of glandular depressions 
and epithelial inclusions without the formation of cysts, rarely occur in 
the ovary. When they do they usually form transition stages to carcino- 
mata and will be considered under that heading. 

(h) Papillary Cystadenoma. 

Frequently the inner lining of a cystoma is not smooth, but shows 
villous projections which extend into the cavity in dendritic ramifica- 
tions. These projections are made up partly of connective tissue ex- 
tending from the wall of the cyst, or else are formed of epithelium, as is 
the case in surface papillomata. Macroscopically the inner surface ap- 



OVARIAN CYSTADENOMATA. 



155 



pears to be covered ^Yit'h larger or smaller nodular structures, of whicli 
some have a smooth and others an irregular surface. At any rate, a very- 
energetic epithelial growth occurs in these formations. This is shown by 
the fact that the epithelial growth is not confined to the inner surface 
alone, but that epithelial masses which preserve a glandular form pene- 
trate to the ivall, extend up to the peritoneum, and may give the outer 
surface of the cyst an irregular appearance (proliferating glandular 
cystadenoma, Waldeyer). 



b 




\ "i^ 







:' £ 


" •' -^ '^^ 




fff/IL 


■ 




' ^1^ 


i 




■J 








f\t^y *" -■- 



jta!f* 



J- 



^ 



•?J>^' 



FiGL'KE 65. — Proliferating Glandular Colloid Cystadenoma. 
ttj papillary excrescences consisting of cylindrical epithelium ; &, colloid masses. 



In this event these formations stand on the border line between 
benign and malignant growths. So long as the outer cyst tvall is not 
penetrated no metastases can be formed in other organs. If these tumors 
are removed at this stage healing usually follows without a recurrence. 
If, hoivever, the outer tvall is perforated, nodules are formed on the 
omentum and the neighboring intestine. At any rate, it seems to be more 
the further growth of epithelial formations than a real occurrence of 
metastases. As soon as the surface is broken through the tumor unites 
with the neighboring organs and a continued growth takes place. Even 



156 OVARIAN CYSTADENOMATA. 

such advanced cases do not have a necessarily unfavorable prognosis 
unless operated upon too late and after a real carcinoma is present. 

The contents of these papillomata are the same as those of the simple 
cystomata. Frequently a colloid degeneration of the tissue takes place, 
so that the contents are mixed with a tenacious colloid mass. In the 
usually homogeneous colloid substances we see now and then the rem- 
nants of epithelial cells. A pseudomyxomatous formation may result 
in the presence of an enormous quantity of a yellow and very tenacious 
fluid. I have recently observed such a case in which the ovarian cyst had 
ruptured, and where the tenacious contents were poured out into the 



,,«-»-r^ ^-»V , 






A. s 






i % •"< 






a 



- "- V- :> 



tei 






.'♦.■^ 






- ,">., 



_~ ^T 



-J 



«^ ■■-' 

Figure 66. — Cxstadenoma Glandulaee Peolifeeum Colloides. 
a, formation of epithelial growths ; 6, solid atypical epithelial growths ; c, colloid 
masses with cell remnants. 

abdominal cavity, with the result that the parietal peritoneum had under- 
gone pseudomyxomatous degeneration. After operation, convalescence 
without reaction. The rupture caused no symptoms. 

Among other changes of the cyst wall and contents hemorrhages and 
calcification must be mentioned, for these are not rare occurrences. Hem- 
orrhages in the wall and into the interior of a cyst result, as a rule, from 
torsion of the pedicle, and may be so severe as to endanger life. The 
contents, especially of small cysts, at times show calcium formations, and 
calcification of the wall may result, either over a large area or only as 
granular deposits. 



OVARIAN CARCINOMA. 



157 



(fi) Carcinoma of the Ovary. 

Carcinoma of the ovary occurs either as a solid tumor or as a de- 
generation of an ovarian cystoma. In the latter case there is formed a 
mixed tumor, adenoma and carcinoma : cystic adenocarcinoma or cystad- 
enoma carcinomatodes. 

A typical alveolar carcinoma infiltrates the ovary with cords of epi- 
thelial cells which in their form and structure are not unlike tubal car- 
cinomata. At any rate, as a rule the type of cylindrical-celled carcinoma 




Figure 67. — Caecinoma of the Ovary. 

a, cancer cells in large round groups; &^ cancer cells in strand-like arrangement (in 
lymph spaces?), between them small-celled infiltration. 



is preserved. In Fig. 67 may be seen the cells lying partly in nests, 
partly in single rows, infiltrating the tissue in strands, as if they were 
lying in preformed channels (lymph spaces ?) . 

The carcinomata cause a rapid enlargement of the ovaries and give 
them an uneven surface by their irregular growth. The malignancy of 
ovarian carcinomata does not seem to be so great in the early stages as 
is the case in carcinoma of the uterus, for metastases do not form so 



158 



CONNECTIVE-TISSUE NEOPLASMS. 



quickly. The first metastases are usually formed on the peritoneum and 
in the omentum through the lymph and blood channels. 

Cystadenomata ichose groivth causes perforations of the tvall not in- 
frequently undergo carcinomatous degeneration. We see, in addition 
to the papillary and glandular growths infiltrating the wall, typical 
cancer nests. The glandular formations are partly lined with several 
layers of cylindrical epithelium. Between the carcinomatous alveoli are 
found spaces filled with round cells. 

Since not only the glandular formations perforating the wall become 
carcinomatous, but also the papillary outgrowths, we frequently find 
free carcinomatous masses in the cyst contents. It is important to recog- 
nize this fact, for if carcinomatous degeneration is suspected such a papil- 
loma should not he punctured before extirpation, for then carcinomatous 
masses entering the peritoneal cavity may easily cause a transplantation 
of carcinoma cells to take place. 




FiGUEE 68. — Glaxdulak Cakcinomatous Cxstadekoma. 

a, glanular formations, partly lined with stratified epithelium (ItJ ; c, small-celled in- 
filtration. 



Such tumors should always be removed in toto. It should also be 
mentioned that carcinomata of the ovary are usually bilateral. Ovarian 
carcinomata of long standing form adhesions va\h the peritoneum, and 
we have a carcinomatous peritonitis with bloody ascites. "While the car- 
cinomatous degeneration of a cystadenoma causes the formation of cyl- 
indrical-celled cancers, squamous epithelial carcinomata have been ob- 
served in dermoid cysts, originating from the squamous epithelium pres- 
ent in them. 

2. Connective- Tissue Neoplasms. 

(a) Fibroma. 

Compared with the epithelial neoplasms, those of the connective tissue 
are rarely observed. Fibromata of the ovary lead to a disappearance of 



DERMOID CYSTS. 



159 



the ovarian tissue, whicli is replaced by fibrous connective tissue. In this 
way the ovary becomes four or five times its normal size, and even larger 
growths occur. The external form of the ovary is usually preserved. 
Such fibromatous enlargements of the ovary may be most often observed 
with large uterine myomata. Fibrous polyps which rest on the surface 
of the ovary have been described. At times adenomatous and cystic 
degenerations of these fibromata take place. 




n-'-: 



a 

f 







h 






~-'S5^ 









e 



0- 






Figure 69. — Sectiox thkough the Wall of ax Ovarian Dermoid Cyst. 

a, stratified squamous epithelium lining the inner wall ; h, sebaceous glands ; c, fat 
tissue : d, connective tissue showing myxomatous degeneration : e, vessels in a layer of 
small-celled infiltration : f^ section of a hair : g, fibrous connective tissue. 



(/j) Myoma. 

Myomata of the ovary are very rare, and when they occur are always 
combined with fibromata. 

(X) Sarcoma. 

Sarcomata are rare and are usually mixed tumors. Sarcomata de- 
rived from vessels are relatively most frequent (endothelioma, perithe- 
lioma ) . There also occurs, though rarely, a sarcomatous degeneration of 
the wall of papillary cystomata and dermoid cysts. Usually they are 
round-celled sarcomata and of a soft consistence. 



160 the parovarium. 

3. The Dermoid Cysts. 

Dermoid cysts differ from other ovarian cysts in that the inner lining 
of the wall has the character of the integument of the external surface of 
the body. We distinguish simple and complicated dermoids, the latter 
being also called " teratoma ta. " 

In the simple dermoids the lining of the inner wall of the cysts 
consists of squamous epithelium with papillae which are very much like 
those of the external skin. In the underlying tissue are sebaceous glands 
and hair. The wall consists, in addition, of fibrous connective tissue in 
which myxomatous changes are frequently observed. In many places 
numerous vessels are found. In the walls of these cysts are found most 
remarkable structures, whose origin is entirely puzzling. I observed in 
one case, which is illustrated, a layer of the wall consisting mainly of 
giant cells. The contents of the simple dermoids consist of a greasy, 
yellow-colored substance, like the contents found in atheroma of the skin. 
As a general rule they do not reach a very large size. In the contents 
are found hair, loose op in bundles. 

The simple teratomata contain, in addition, bone in pieces or as fiat 
structures and also teeth. The complicated forms contain various struc- 
tures of the body, and may consist of most varying tissues, such as brain 
substance, nerves, mammary tissue (?), etc. (See Part III.) 

It should be remarked that the contents of dermoid cysts may be 
infectious. The rupture of these cysts during operation has frequently 
caused death from septic peritonitis. 



PAROVARIUM. 



1. NOEMAL ANATOMY. 



Between the ampulla of the tube and the ovary lies the parovarium, 
the remains of the sexual portion of the Wolffian body. It consists of a 
row of communicating canals which are lined with ciliated epithelium. 

Parovarian Tumors. 

The parovarium is of practical value because very large cysts origin- 
ate from it. These have a very thin, translucent wall and generally clear 
watery contents. The inner lining is almost always ciliated epithelium, 
even in larger cysts. These cysts are macroscopically recognizable, for 
the ovary is distinctly separated from them while they lie in close con- 
tact with the tube. The parovarian cysts generally contain only one 
chamber. 

The parovarium has received considerable attention through the 



PAROVARIAN CYSTS. 161 

studies of v. Eecklinghausen, who is of the opinion that the adenomy- 
omata and cyst adenomata of the uterus and tubes originate from epi- 
thelial remnants of the Wolffian body. The glands which are found in 
these myomata correspond in their arrangement and structure to the 
structure of the glandular elements of the Wolffian body, point for point. 
As regards the relative dependence of the glands and the muscle tissue 
in these adenomyomata, v. Recklinghausen has arrived at the conclusion. 



I 



0^ ^ ^,r# 






^^ ^ J r^c ^\''} ^^i ' ' ''if^' 



"-•i?; 



.i^y^ 






^ j:<^A.:^^^^%lh^^^\. " '^^' ^^^'^.^,?Tk /J 






> - .- r> - ,^-i'^. 'y..Ml .♦ ,^vi^^. ^ --^ . ^ ,c^ . ^ ^ 













fr^ 









15 



Figure 70. — From the Wall of a Dermoid Cyst. 
a, giant cells ; &, connective-tissue stroma with spindle cells. 

which I shall quote literally because of its importance : " In all smaller 
tumors of the body of the uterus and the tubal cornua the formation 
of muscle fibres goes hand in hand with the adenomatous formation and 
is proportional, which is the more evident the more distinctly muscle 
fibres are formed around the tubular glands and the groups of glands. 
Where this condition is most fully developed, and where the moire strands 
appear most distinctly, there tlxe glands are to he considered as the real 
cause of the myomatous formation. Just as during the embryonal 
11 



162 



ADENOMYOMATA V. RECKLINGHAUSEN. 



period the epithelium is first present, before the connective tissue and 
the enveloping muscular tissue, so also in its later growth does the gland 
become surrounded with a myomatous sheath only after it is itself com- 
pleted. This sheath is therefore formed secondarily, and later on it may 
react upon the glandular structures and cause processes of growth in 
them. " It is not sufficient to accept these remnants of the Wolffian body 
alone as the cause of the larger tumors of this form. In such cases all 




Figure 71. — Teratoma of the Ovary. 

The cyst is opened. Within is seen the skin-like innei" wall with pores and a bone 
resembling a jaw in which are firmly embedded seven teeth. From the other end of the 
skin covering this bone grows hair which has formed a long, dense lump. 



those conditions must have been present which make muscular tissue sen- 
sitive and likely to hypertrophy. Even though these valuable investiga- 
tions have given those myomata a distinct position because of their origin, 
they are still to be distinguished by their location and their rougher 
structure from the ordinary myomata. v. Recklinghausen says : 

' ' The adenomyomata occur most frequently in the body of the uterus 
on the dorsal wall, and in the tubal cornua on the cranial side. They 



ADENOMYOMATA V. RECKLINGHAUSEN. 163 

grow either from isolated cell centres and form large masses, generally 
in the vascular and in the peripheral layers of the wall, or else they 
occur in numerous centres close to each other, or else quite scattered 
without any demarkation from the remaining substance and are not lim- 
ited to any layer of the uterine wall. They may make their way into 
the inner layers of the uterus and tube wall, and form central tumors. ' ' 

The majority of examiners who have tested these observations on their 
own material have come to the same conclusion as v. Recklinghausen. 
That these examinations have not a theoretical anatomical interest alone 
is proven by the clinical observation that these tumors occupy a special 
position and demand a different therapeutic treatment from the ordinary 
myomata. The prognosis of this affection is, according to Freund, who 
states his views in connection with v. Eecklinghausen 's work, much 
graver than is the case ivith the ordinary myomata. On account of the 
presence of the numerous epithelial formations there is also greater dan- 
ger of carcinomatous degeneration. (See Part III.) 



PART III. 

EMBRYOLOGY OF THE FEMALE GENITALL\ AND 

THE PATHOLOGICAL GROWTHS DEVELOPING 

FROM EMBRYONAL STRUCTURES. 



No region of the body goes through more interesting and important 
changes in the process of embryonal development than does the uro- 
genital system. "We find at first the formation of the ' ' head kidney, ' ' or 
pronephros, with its excretory duct, the Wolffian duct. Its place is then 
taken by the mesonephros, or Wolffian body, with the same excretory duct. 
Both are replaced by the permanent kidney, or nephros, the Wolffian body 
becoming the parovarium and the duct becoming the canal of Gartner. 
We observe their close relation to the ducts of Miiller (tube, uterus, va- 
gina), and finally to the formation of the sexual gland (ovary). 

Already in connection with the formation of the primitive furrow a 
development of part of the pelvic organs is observed, namely, the cloaca 
with its subsequent divisions, the urogenital sinus and the end intestine, 
and their openings, the urogenital opening (vestibulum) and the anal 
opening. From the very beginning there is an intimate connection be- 
tween the end intestine and the genital and urinary passages. 

^ ' \ 

/ "- - — ~=- Medullary plates 

Vesicle ^ - " ' 



Mesenteric canal — f 






Cauda or tail 



Primitive furrow 



Cloacal membrane 



Figure 72. — Scheme of Embryonal Vesicle^ Caudal End. (Waldeyer.) 

This may be seen in Fig. 72, which shows schematically the posterior 
end of an embryo on its vesicle. The medullary plates (tori meduUares) 
are not yet closed, so that the external opening of the neurenteric canal 
is visible. The following portion of the primitive furrow (sulcus primi- 
tivus) is closed. Posteriorly is the cloacal membrane where the anus 
perforates later. Anterior to this the cells of the primitive trace, through 



CELOM. 



165 



decided growth, have formed the caudal tubercle or ' ' tail. ' ' At the cloacal 
membrane the intestine ends blindly. On the anterior surface appears 
the beginning formation of the allantois. 

Fig. 73 shows in transverse section the middle blastodermic layer of a 
human embryo, still without primary vertebra and chorda. Through sub- 
sequent division of the mesoderm it is separated and segmented into two 
layers, a parietal and visceral. There results then a symmetrical space 



Amniot. 
mesoderm. 
Amniot. 
ectoderm 



UmMl. ves- 
icle meso- 
derm. 



y ^ , — 



^ 



-..;- 



^.aii^*---''?) 






ri 






^ 



<^ 






Ectoderm 
Mesoderm, 

Mesoderm, division 
Entoderm 



Figure 73. — Middle Blastodermic Layer of a Human Embryo^ still without Primary 

Vertebrae. Transverse Section. (Keihel.) 

called "celom/' the walls of which gradually approach in the anterior 
median line and form the cylindrical body shape through their union, 
with resulting closure of the intestinal canal and the body wall (Fig. 74). 
This space in the embryonal body, called ^'celom," is intended to ac- 
commodate the internal organs or viscera. It is divided into three spaces : 
1, primitive pericardial space ; 2, the pleural spaces ; 3, the abdominal 
cavity (Fig. 75). . 



Ectoderm 



Parietal mesoderm 



Visceral mesoderm 



Entoderm 




— — Medullary canal 



Vegetative canal 
Celom 



.> Umh. vesicle 



Figure 74. — Animal and Vegetative Canals. Schematic. (Kollmann.) 



The parietal layer of mesoderm (the celom wall [Fig. 75] ) consists of 
mesoderm from which develop the connective tissues and involuntary pale 
muscle fibres. Externally it is covered by ectoderm and internally by 
the celom epithelium, which consists of mesoderm cells. 

The visceral layer of the mesoderm also covers, on the posterior body 
wall, the entire intestinal canal (Figs. 74 and 75), forms the intestinal 
mesenterium commune (Fig. 80), and furnishes the muscle layers for the 
intestine, and connective tissue cells and muscle fibres for its mucosa. It 



166 CLOACA. 

is, therefore, naturally lined by entoderm, and is itself covered ex- 
ternally by celom epithelium. This epithelium is, as may be seen later, 
the point of location for the formation of the generative organs. 



I>v 



Oral space 

1 Branchial arch 

2 Branchial arch 

Parietal wall of 
mesoderm 

Celom 1 

Anterior intes- 
■ tine 

Middle intestine 
and umMlical 
vesicle 



>. Celom 2 



End intestine 



Abdominal pedi- 
cle. 



PiGUEB 75. — Human EmbktOj 2.4 Millimetres Long^ with Heart and Umbilical 
Vesicle Removed and Umbilical Pedicle Cut. (After His.) 

The lower end of the intestine (D) may be seen in Fig. 76. It empties 
into a blind sac (cloaca), which is continued into the tail-like end of the 

Celom Aorta 
a. umh. d. _ 



Allantois duct 
Cloacal membrane. 




Schw. ' .. > ' Chorda 



Figure 76. — Caudal End of Embryo 3 mm. Long. Reconstruction. (Keibel.) 
CI., cloaca ; Md., medullary canal ; Schto., tail ; Schw. D., caudal intestine. 

body (Schw.). The cloaca is an entodermal space into which the allan- 
tois duct empties ventrally and the intestine dorsally. The allantois 
duct also comes from this general entodermal space. That part of the 



PRONEPHROS. 



167 



allantois caudal to the duct, and which is a continuation at the expense 
of the cloaca, does not really constitute the allantoic duct. A sharp line 
between the original ventral portion of the cloaca and the allantois does 
not exist. In embryos of three millimetres the medullary plates are not 
yet closed. The caudal intestine (ScJnv. D.) is present in the tail. This 



Sklerotom 



Myotom 
Myocel 



A orta 
Glomerulus 



Head kidney 
or pronephros 



Celom 



Intestine 



Figure 77. — Transverse Section in the Region of the Pronephros, or Head Kidney 

(ICHTHYOPHis Gut). (After Semon.) 



caudal intestine is situated behind the location of the future anus, and is 
therefore called "post-anal intestine." In Fig. 76, an embryo of fifteen 
to eighteen days, the cloaca! membrane does not cover the entire cloaca. 

Pronephros.— In the parietal mesoderm, where the segmented 
portion goes over into the unsegmented, is situated the "middle plate." 
In this area the ' ' head kidney, ' ' or pronephros, develops, consisting of a 

Parietal mesoderm Mesoderm Ectoderm 




Visceral mesod. 



Entoderm 



Aorta Primary Medullary 

vertelira plate 

Figure 78. — Transverse Section through a Rabbit Embryo of 8 Days and 21 Hours, 
WITH 10 Primary Verterbrae, Caudal to the Last Primary Vertebra. 

(0. Scliultze and R. Bonnet.) 

series of tubules connected with the celom. Each opening into the celom 
is funnel-shape and ciliated. Each of these tubules is called "a diverti- 
culum. ' ' At their peripheral ends these diverticula unite into a common 
canal which lies close to the ectoderm, the Wolffian duct. The duct ex- 
tends over a considerable space, and is thus connected with the celom 
by several consecutive ' ' head-kidney ' 'tubules. These tubules lie near the 
aorta; their glomeruli develop to the right and left of the mesentery 
(Fig. 77). ^ . 

Mesonephros.— The pronephros is retained in certain fishes. In 



168 



MESONEPHEOS. 



amphibise it disappears; in aniniot^ evidences have been found. Ee- 
mains have been described in rabbits, and evidences of its existence are 
claimed to persist in man, and it is probable that it develops in the 
same manner as in mammals. 

Parietal mesoderm Ectoderm Primary vertebra 



Nephrotom 

Funnel shaped 
opening 




— Medullary canal 



§. Chorda 



Visceral mesoderm Entoderm Aorta 
FiGTJEE 79. — Teansveese Section theough Rabbit Embexo of 8 Days and 23 Hours, 

WITH 13 Peimaey Veetebeae. (0. Schultze.) 

Shortly after the formation of the pronephros, in animals in which 
its existence is only rudimentary, there develops the mesonephros, or 
"Wolffian body. It originates immediately posterior to the pronephros on 
the following section of the Wolffian duct. Medial to the pronephros, 
between the middle plate and the primary vertebrae, the "blastoma" of 
the Wolffian body appears. 



Medullary canal 
Primary verte- 
bra 
Celom 
Mesentery 

Celom 

Allantois canal 

Vena otnphal. 
mesent. 



Abdominal pedi- 
cle 



Aorta - 

Primary kidney ^ V^^^ 1 i ^^=^ i 

or mesonephros OTN/^' n ff^x 

Intestine —"—^^^■X^U V'% 




Art. umbilicalis 




FiGUEE 80. — Human Embexo 5 mm. Long. (After His.) 
The transverse section includes the umbilical pedicle also. 

From this develop, parallel to the formation of the segmental pri- 
mary vertebrae, segmental bodies, or " nephrotoms, " communicating with 
the celom by funnel-shaped spaces (Fig. 79). 



JMESONEPHROS. 



169 



These form the tubules of the Wolffian body, which at their outer end 
empty into the Wolffian duct. The Wolffian body thus develops at the 
side of the vertebrae and retroperitoneally. Its surface looks toward the 
celom. Medially it borders on the aorta, and posteriorly pn the posterior 
body wall (Fig. 80). 



WoJifian 
duct 




-..'-=^ Mesoderm 



y 



S? 



Malpighian 
'body 

Epithelium 
EpitJielium 



Germinal 
layer 



Figure 81. — Wolffian Body Tubules, Combined Drawing. Human Embbyo 10.2 mm. 

Long. (After Kollmann.) 

Near the celom develop capsules with glomeruli. The Malpighian 
bodies are like those of the kidney with Bowman's capsule and vessel 
knots. The tubules are twisted and lined with cuboidal epithelium ; the 
part near the glomerulus is ^vide and is lined with large cuboidal ciliated 



"Slesoderm, 



Cranial pro- 
longations 



Umbilical vesi- 
cle 

Navel cord 
Caudal intes- 
tine 

Kidney l)uJh 




Cephalic intest. 

Lung formation 

j Liver formation 

> Stomach 

! Pancreas 

I Mesenterium commune 

I 'Wolffian tody 

I Allantois duct 

Caudal end of intest. 



Figure 82. — Human Embryo 5 mm. Long. Reconstruction. (After His.) 



cells having secretory function. Toward the duct the tubules become 
narrower, and, like the Wolffian duct, are lined with much lower cu- 
boidal cells. 

The proximal portion of the Wolffian body is of simple form and is 
called the ' ' cephalic part. ' ' Its tubules at an early period lose their cap- 



170 



WOLFFIAN DUCT. 



STiles and glomeruli, and come into close relation with, the sexual gland 
(ovary), and it is therefore called the "sexual part" of the Wolffian 
body. The distal part or caudal portion has secondary tubules united to 
the main or primary tubules. The Wolffian body extends down into 
the pelvis, its upper end extends up to and behind the heart (Figs. 82 
and 95). 




Ectoderm te-V^.o^ ^»E,.r»:rt2#^ <s. 

Mea. canal. —-^^^<^%<^^it^®S^-^ 

Chorda -.- f-%r^ ' 

Aorta .— -. — -fefufe® 

Entoderm ,. ,^ 

Figure 83. — Teansveese Section through Rabbit Embryo^ showing Origin 

OF Wolffian Duct from Ectoderm. 

Wolffian Duct. — The excretory duct or Wolffian duct develops 
near the ectoderm. According to some it develops only near, according 
to others partly from, and according to most recent views entirely from, 
the ectoderm. It may be seen in Fig. 83 that the Wolffian duct has not 
yet entirely separated from the ectoderm. The Wolffian duct grows 



Duct of Mueller 
Celom 




^^^ Med. canal 

*w^ ^mk Myotom. 

*^\-^a-\: Chorda 

'^•- V?\ / 1 Aorta 

Wolff, 'body 
Mesentery 



Intest. 
canal 



Figuee 84. — Teansveese Section through Guinea-Pig Embryo. 

downward by increase of its own cells, becoming further and further 
separated from the ectoderm until it reaches the cloaca. 

After the formation of the cylindrical body shape the Wolffian duct 
is situated in its entire course near the celom close to the Wolffian body, 
as may be seen in Fig. 84. 



WOLFFIAN DUCT. 



171 



The tubnles of the Wolffian body have developed in the mesoderm 
from the so-called "nephrotoms. " These are said to be part of the pri- 
mary segments, the remaining portion of these segments forming the 
myotom (muscle plate) and the sclerotom, from which develops the 
skeletal tissue. Although these nephrotoms develop in mesoderm, Spee 
and others hold that their cells come partly or wholly from the ectoderm. 

Wolffian hody 
Celom Wolffian duct 



Allantois duct 




\ 



■trnrn^ iJ 



Cloacal memh 




Wolffian duct 
Chorda 
Wolffian duct 



Figure 85. — Human Embeto 4.22 mm. Long. (After Keibel.) Caudal End. 

In Fig. 85 are seen in section the celom, the Wolffian body and the 
Wolffian duct, and the entrance of the Wolffian ducts into the ventral 
portion of the cloaca. In embryos of three or four millimetres the Wolff- 

Wolffian duct 
D. Intestine _'__^^ , Kidney Tiull), or ureter 



AllD. 





Cloacal memhrane i 
Schw. Yf' 

Caudal intestine 
or Schw. D. 



Figure 8.6. — Caudal End of Human Embryo 6.5 mm. Long. (After Keihel.) 



Chorda 



ian duct and the intestine empty at the same level into the entodermal 
cloaca. The extent of the cloaca is now greater, and is entirely covered 
by the cloacal membrane. The dilated portion above the letters CI, Fig. 
85, can no longer be considered a part of the allantoic duct, for this 
dilatation is to form a portion of the future bladder. In Fig. 85 the 



172 



THE '^TATL.'^ 



medullary canal, chorda, and caudal intestine are closely united in the 
tail. Further up the chorda is separated from the end intestine. 

In Fig. 86 the cloaca is smaller, and the caudal intestine is clearly 
marked off from the cloaca. The cloaca is now continued dorsally into the 
true intestine, and ventrally into the primary formation of the bladder 
(H). The Wolffian duct (Wf.D.) empties into the cloaca in the area 
which marks oft' the cloaca on the one hand from the intestine (D.) and 
the bladder on the other. The part of the cloaca into which each Wolffian 
duct enters belongs to the future bladder and urethra. 

Ureter.— From the lower end of each Wolffian duct develops a 
kidney bulb, the primary formation of the ureter. It lies dorsal, but later 
lateral to the Wolffian duct (Fig. 86). 

The prominent tail subsequently disappears at an early period. Be- 
tween the tail and the primitive anus appears an epithelial lamella eon- 

WoJffia^i duct 



AUantois duct 



y..-^ 



Urinary Madder .^-£1 



Cloaca 
Cloacal membrane 



C€lom 



Kidney pelvis 



End intest. 



Caudal end 



Figure 87. — Pelvic End of Human Embryo 11.5 mm. Long (41^ Weeks), 
(After Keibel.) * Septum Uro-Rectale. 



sisting of two layers, which, however, is only temporary. There occurs 
a growth of connective tissue between the primitive anus and the base of 
the tail, forming a prominence of mesoderm called ''the post-anal prom- 
inence. ' ' Through the growth of the post-anal prominence the tail is de- 
prived of its epithelial covering and the above-mentioned lamella is 
opened, the upper layer covering the lower surface of the post-anal prom- 
inence and the lower layer covering the ventral surface of the tail. The 
caudal intestine becomes gradually reduced to an epithelial strand. The 
tail also disappears under normal conditions. In the disappearance of 
this area the same processes take place as occur in the penis in large 
inguinal herniae, where the penis is robbed more and more of its skin^ 
through decided stretching of the surrounding tissues, until it disappears 
finally under the surface. By the withdrawal of this tail into the trunk 
epithelial remnants of the caudal intestine may also be carried along. 
Such epithelial remains would subsequently lie dorsal to the future 



CLOACA. 



173 



rectum — a point of importance with regard to rectal carcinomata and 
tumors of this region. At times the tail or the caudal intestine persists 
in human beings. 

At a later stage intestine and bladder empty into a smaller cloaca and 
part of the future urethra is present (Fig. 87). The ureter now empties 
into the lateral wall of the "Wolffian duct instead of the dorsal. The celom 
keeps pace with the gradual separation of the intestine on the one hand, 
from the bladder and urogenital sinus on the other hand. The cloaca has 
become partially divided into an anterior portion, the future bladder 
and urethra, and a posterior portion, the future rectum. Into the an- 
terior division empty the Wolffian ducts and the ureters. The cloaca 
has been thus divided by tAvo endothelial folds which unite in the middle 
line, forming a septum. This septum extends down toward the cloaca I 
membrane and forms the primitive perineum. Mesoderm completes the 
di\dsion, forming the future urorectal septum. Mesoderm pushes the 
intestinal canal against the sacral vertebrae, and the anterior canal is 
pushed against the abdominal wall. AVe have then later, on extension 

Cliorda 

Med. canal 




Cloacal memirane 



Scuir. 

Figure 88. — Human Embryo 14 mm. Long. (Keihcl.) 

of the dividing membrane, the urogenital sinus, which is that part of 
the former cloaca below the entrance of the Wolffian ducts (Fig. 88). 

In Fig. 88 the tail is small, but lies close to the still closed anal forma- 
tion. The medullary canal still extends into the tail. A definite division 
between the urogenital sinus and the bladder is not distinct. The AYolff- 
ian duets and the ureters now empty separately into the bladder. The 
celom has descended much lower, especially laterally. An opening for 
the urogenital sinus is present, and the genital prominence (G.H.) is well 
developed. The upper end of the cloacal membrane is represented by 
the epithelial prominence (Ep.H.). 

In embryos of twelve millimetres the allantoic duct is closed before 
reaching the umbilicus, and is only an epithelial strand. As at this 
period the glomeruli of the Wolffian body are secreting actively, Nagel 
claims that the cloacal membrane is already perforated. The view ex- 
pressed above, that of Keibel, is undoubtedly correct, and the secretion of 
the Wolffian body gains an exit only in embryos fourteen millimetres 
long. 



174 



DUCTS OF MULLER. 



Ducts of Mueller.— The ducts of Miiller develop on the celom 
epithelium at the outer side of the Wolffian body. Each commences, in 
embryos of twelve millimetres, as a short funnel, open above, with a 
solid pointed end, and in its growth follows closely the course of the 
Wolffian duct until it reaches the cloaca. It is said by some, for this 
reason, that the ducts of Miiller are in part or whole given off by the 
Wolffian duct, but this is not probable (Fig. 89). 

At times the inversion of the celom epithelium is repeated, so that 
a longer or shorter accessory tube is formed. An entirely double duct of 
Miiller has been found on one side, and accessory tubal ostia not so rarely. 
The accessory tubes are usually shown by a more or less distinct fimbri- 
ated end in the region of the abdominal opening of the normal tube. 
These are to be distinguished from accessory openings in the tube itself, 
which may be formed through a union between the epithelium of the 







FiGUEE 89. — Teansveese Section theough the Uppee End of the Wolffian Body of 

A Female Embeyo 12 mini. Long. (Nagel.) 
1, duct of Mueller ; 2, Wolffian duct ; 3, celom epithelium of the mesonephros ; 4, 
a glomerulus of the Wolffian body ; 5, blood vessel. 

duct of Miiller and that of the Wolffian duct— a fact which perhaps ex- 
plains the view that the former is a product of the latter. Such acces- 
sory openings may result from thinning and perforation of the tube wall 
at such points of union. There are found in the walls of these tubes 
thinned spots, through which the mucous membrane may be recognized. 
These may, however, result from imperfect closure of the original funnel- 
shaped inversion. The ducts of I\Iiiller enter the urogenital sinus in em- 
bryos of twenty-five to thirty millimetres. The end of each duct is solid. 
The ends of the duct of Miiller cause a prominence in the urogenital 
sinus, called ''the prominence of Miiller" (Fig. 94). The ureters are 
now situated cranially to the Wolffian ducts. 

The area above the point S, Fig. 90, is the future bladder and urethra. 
The opening of the AVolffian ducts marks the division between the future 
urethra and the urogenital sinus. The wall between the two ducts be- 
comes the hymen. 



CLOACAL MEMBRANE. 



175 



Cloacal IMembrane. — The cloacal membrane is in greatest pan 
entodermal, and only partly ectodermal. It appears to develop from the 
posterior end of the primitive trace. In embryos of 4.2 mm. it extends 
over the entire end of the cloaca (Fig. 85). The frontal dividing wall 
mentioned above has divided the cloacal membrane into an anterior part 
or urogenital plate, and into the anal membrane which closes the intestine 
and which later marks the division between the ectodermal and entoder- 
mal portions of the rectum. The perforation for the urogenital sinus 
occurs earlier than that for the anus. 

The area where the anus perforates is represented by a groove, the 
anal groove. From here the now elevated cloacal membrane extends be- 
tween the sexual folds of the genital prominence, forming the cloacal 



Sexual or 
genital 
prominence 
G-lans 
Epith. prominenct 
Glaus 
Epith. 
prominence 



Genital 
projections 
(Labia majora) 

Genital folds 
(LaMa minora) 





Coccygeal prominence 
Anus 

Coccygeal prominence 



H, bladder ; 8, point of future hymen ; C, fold of Douglas. 
Figure 90. — Caudal End of Human Embryo 29 mm. Long. (KeihelJ 



plate. Its upper end forms the epithelial prominence. The cloacal plate 
is not perforated so long as any cloaca remains. When the cloacal plate 
becomes thinner and thinner it still covers the entodermal sinus and the 
entodermal intestine, the sexual prominence, the anal groove, and divides 
the primary perineum into a right and left perineal half, which pass 
anteriorly into the sexual folds. These halves (mesodermal) pass poste- 
riorly into the anal region as anal prominences. The space (imaginary) 
covered by the cloacal plate has been called "ectodermal cloaca." As 
said before, the opening for the sinus occurs first, and later, in the 
ninth week, that for the anus. The perineum is formed by the union of 
the perineal folds in the middle line forming the perineal raphe. The 
sexual folds form the labia minora, the sexual or genital prominence 



176 



ANUS. 



forms the clitoris. The anus develops entirely in the region of the 
ECTODERM. The anal prominences, mesodermal, unite above the primitive 
perineum and surround in this manner the above-mentioned ectodermal 
anal groove. 

After the formation of the permanent perineum, the ectodermal 



Mesoderm 

Excavatio recto- 
uterina , 

Genital or 
sexual strand^ 

• Excavatio 
utero-vesicalis 

Bladder 




Ureter 
Intestine 
Wolffian duct 

Mueller's duct 



„ _ Ureter 



FiGUEE 91. — Pelvic End at the Level of the Bladder^ with the Genital ok Sexual 
Strand of the Left and Right Sides. Human Embryo of 9 Weeks. (Kollmann.) 

cloaca has been divided into the ectodermal sinus urogenitalis and into 
the ectodermal intestine (anus). The former becomes that part of the 
vestibule of the vagina which is surrounded by the previously mentioned 
sexual folds (labia minora). These changes may be observed by a com- 
parison of Figs. 88 and 90. 

Into the celom there project from the dorsal wall of the body three 



Excav. recto-uter. 



Genital strand, 
later Lig. ut. lat. 



Urinary Madder . 




Intestine 

Ureter 
Wolffian duct 

Mueller's duct 
Ureter 



Figure 92. — Genital or Sexual Strand. Human Embryo of 9 Weeks. Transverse 

Section. (Kollmann.) 

folds, one containing the intestine and the other two containing the 
ovary, WolfBan body, Wolffian duct, and the duct of Miiller of either 
side (Fig. 91). 

From the ventral wall is a fold in which is situated the bladder. In 
Fig. 91 the folds containing the ducts of Wolff and of Miiller have not yet 



UROGENITAL FOTiD. 



177 



united. A section made a little further down shows these folds, called 
"genital strands," united, and the celom has thus been divided into an 
anterior and a posterior division. 

The stroma of the Wolffian body is a richly vascular embryonal con- 
nective tissue or myxoid tissue. The AYolffian body is enclosed in a mes- 
entery which becomes more distinct and movable when the Wolffian body 
begins to disappear. The distal continuation of the Wolffian body is the 
urogenital fold. Since this fold makes a spiral twist, so each duct of 
]\liiller lying in it, while situated in its upper part external to the Wolff- 

8 3 




5 6 

FiGUEE 93.— Schematic Figure of the I>-ternal Genitalia of a Female Human Embryo 

OF M Centimetre. (Nagel.) 
1, Wolffian body ; 2, sexual gland (ovary) ; 3, Wolffian duct ; 4, duct of Mueller ; 5, geni- 
tal strand; 6, opening of lower end (future vagina) of genital strand into the urogenital 
sinus ; 7, gubernaculum Hunteri ; 8, diaphragmatic band of the mesonephros. 

ian duct, makes a spiral twist in its lower part and lies Menial to the 
Wolffian duct (Fig. 93). The ducts of Miiller enter the urogenital sinus 
in embryos of twenty-six to thirty miUimetres. The end of the duct is 
solid. Since the ureter is situated higher up at this time, we have two 
Wolffian ducts and two ducts of Miiller entering the urogenital sinus, 
forming the "prominence of Miiller." The intervening tissue forms 
the future hymen (Figs. 93 and 94). 

The folds in which the ducts of Miiller are situated have united, and 
so have the ducts of Miiller. As mentioned, the tissue in which the ducts 
of Miiller and the ducts of Wolff are surrounded is called "the genital 

strand. ' ' 

Fig. 94 shows the prominence of Miiller (Mll.P.), the ducts of Wolff 
12 



178 



DUCTS OF MULLER. 



(Wf.B.), the ducts of Miiller (WIll.D.), the ureter (V.). Tr.L, 
represents the trigonum vesicse. We see the ducts of Miiller united down 
to their lower end, where they again separate, bending forward at a sharp 
angle. The ducts of Wolff begin to retrograde, and in embryos of four 
centimetres only the ducts of Miiller enter into the urogenital sinus. The 
upper end of the mesentery of the Wolffian body extends to the dia- 
phragm and becomes the diaphragmatic band, or plica phrenico-meso- 
nephrica (8, Fig. 93). From its lower end extends the plica inguino- 
meso-nephrica. In it are strands of muscle fibres with connective tissue. 
It is attached proximally to the ducts of Wolff and Miiller at the point 
where the ovarian ligament is also situated. It extends distally into the 
subperitoneal tissue of the abdominal wall and into the region of the fu- 
ture inguinal ring (7, Fig. 93). On the disappearance of the Wolff- 
ian duct it enters into the uterine wall. From the lower end of the sexual 
gland extends the fold of the Wolffian body. In it is a band of muscle 
fibres and connective tissue attached to the closely grouped Wolffian and 

Mil. D. Wf. D. 




to / 



Wf. D. 



H. R. 



Wf. D 



) €Mj 



Sin. ug. _!_ 




Fig. 94. 




Prominence 
of Mueller 
Mil. P. 



Sin. tig. 



Fig. 94a. 



FiGUEE 94. — Ducts of Mueller and Wolff^ etc., of Figure 90 Magnified. 

Miiller ducts. It represents the ovarian ligament. As the Wolffian duct 
disappears it is connected later only with the duct of Miiller. 

The ducts of Miiller form an angle which marks off the lower end of 
the tube from the beginning of the uterus. It is from this point that the 
gubernaculum Hunteri, the future ligamentum teres, is given off. The 
first union of the ducts of Miiller occurs in the eighth week. The union 
is complete at the third month up to the ligamentum teres. Even at this 
time the utero-vaginal canal shows a curve with its concavity anteriorly. 
The walls of the tube and uterus come from the mesodermal elements of 
the Wolffian body (and the urogenitalfold). 

Yagina.— The vagina develops from the lower end of the ducts of 
Miiller. The final separation between the vagina and uterus is found in 
embryos of ten to fourteen centimetres, although at an earlier period the 
distinction is evident through a difference in the character of the epithe- 
lial cells. The vagina develops from the lower end of the ducts of Miiller. 
At the same time the urogenital sinus becomes shorter. With the growth 



VAGINA. 



179 



of the vagina and the shortening of the sinus the formation of the 
urethra goes on. The longer the vagina and the shorter the sinus the 
nearer does the opening of the urethra approach the cloacal groove, until 
it and the vagina assume their normal situation, the sinus forming the 
vestibule. The portion of the vestibule of the vagina immediately sur- 
rounding the urethral opening, and the external opening of the vagina, 
the upper surface of the hymen, and the region of the openings of the 
glands of Bartholini, belong to the entodermal urogenital sinus. The ecto- 
dermal urogenital sinus forms that part of the vestibule covered by the 
labia minora. 




— „-^ Middle 'brain 





1 


'"1 


Large 'brain 


Post, drain ~=^ 


~~/ ' i 


. _:4 




1 Branchial _ 








cleft 


- 


.. —=, 


Forehead 


Heart -...- 

1 
I 


i 




Lung sacs 


Intestine ^-.l 










_if ^1 







Mesonephros 
or Wolffian — — 






body 


5 . i- • 




Germinal fold — 




1 




future ovary 


Celom 


•• • s. • 


. . — , 


Abdom. icall 


Extremitii —- 




^ 


Genital 

prominence 

Caudal end 


J^ %MJ VI \/ t It, %/ V %J ■■" " 


\ '' 





FiGUKE 95. — Human Embryo ix the Fifth Week, the Anteeior Body Wall Removed^ 

THE Mesonephros Exposed. (Kollmann.) 



As soon as the ureters enter independently into the cloaca (12-13 mm.) 
the development of the bladder begins through the change of this anterior 
portion of the cloaca into a spindle-shaped tube. The part not used for 
the bladder forms the urachus. Through growth of the future trigonum 
the entrance of the ureters is more and more separated from the Wolff- 
ian ducts. It must be mentioned that ]\Iinot and others consider the 
anterior part of the cloaca, which the Wolffian ducts and ureters enter,, 
as belonging to the allantois and not to the cloaca. As cloaca and al- 
lantois are both derived from the same entodermal space such a distinc- 
tion cannot be clearly defiiaed. 

Kidney. — The ureter lies at first dorso-medial, then dorsal, and 



180 



KIDNEY. 



then dorso-lateral. Its upper end develops, forming the pelvis of the kid- 
ney. From it develop the kidney calyces, and from these the kidney 
tubules. According to certain authors, the canal system of the kidney 
comes from the ureter, according to the usual form of glandular gro^vth. 
According to others the kidney develops from two separate formations : 
the medullary substance and the collecting tubules from the ureter, the 
cortical substance and the twisted tubules from a specific formation, the 
kidney blastoma. 

Ovary. — In embryos of eight to twelve millimetres the celom epi- 
thelium on the inner side of the A¥ol£fian body becomes thickened. 

This constitutes the germinal fold, which has been outlined distinctly 
from the stroma of the Wolffian body. Through a decided increase in the 
cells of this germinal epithelium and a change of a large part of these 
cells into primitive ova, the parenchymatous ovary is formed. Connec- 




FiGUEE 96. — Section through the Oyart of a Human Embryo with a 
Body Length of 11 Centimetres. (Nagel.) 
1, External layer of primary ovary (later germinal epithelium of the ovary) ; 2, com- 
partments of ova; 3, stroma (vessels). 



tive-tissue cells and vessels grow f7^om the stroma of the Wolffian tody 
into the germinal epithelium, dividing it into compartments. These com- 
partments consist of primary ova and germinal epithelia, and are divided 
into constantly smaller compartments by the growth of connective-tissue 
stroma. 

Finally, we have primary ova surrounded by a layer of germinal 
epithelium, the so-called "primary follicles." The superficial layer of 
the germinal epithelium remains as a simple layer of cylindrical epithe- 
lium covering the ovary. Most authorities believe that the follicle epithe- 
lium is derived from the germinal epithelium. Others claim that it 
originates from the connective-tissue stroma of the Wolffian body. 

As regards the germinal epithelium, it is said to originate from the 
celom epithelium, which is itself mesoderm. It may be said that Spee 
and others hold that the germinal epithelium is a derivative of ectoderm 



OVARY, 



181 



cells carried to their point of development by the "Wolffian duct and the 
Wolffian body. That this is possible may be seen by a comparison of Fig. 
83, where the Wolffian duct lies near the ectoderm, and Fig. 84, where 
all these structures are situated near the celom to the right and left of 
the intestinal mesentery. 

In the descent of the ovary the gubernaculum Hunteri plays an im- 
portant role, for the ovary may be carried into the canal of Nuck. 

The follicles in the ovary, after their formation, are forced more and 
more into the periphery, and in the newly-born we can see the connection 
between the youngest primary follicles and the germinal epithelium cov- 
ering the ovary. These are not to be confused with depressions and fur- 
rows found on the surface of the ovaries of the newly-born. The major- 
ity of ova and primary follicles degenerate during intrauterine life 
and in the first year. Their place is taken by loose connective tissue. 
Finally, Ave have a surface layer with primary follicles, called ''zona 



/f 



■ t \ - 




Diaphragttiatio 
hand 

i -.^fl„ Germinal gland- 
*l ovary 

Wolffian hody 



%, — Wolffian duct 



G-uhernaculMm 
Hunteri 



— Allantois duct 



FiGUEE 97. — Wolffian Body and Ge>ekative Gland (Ovaey), Human Embeto 17 mm. 
LONG;, AT Beginning of the Sixth Week. To the Right the Wolffian 

Duct is Opened. (Kollmann.) 



parenchymatosa, " and a deeper layer of connective tissue and vessels, 
called the "zona vasculosa." 

In the development of the ovary there pass out from the germinaj 
epithelium thinner or thicker cell bands, the so-called "tubules of 
Pfliiger. " In them are found follicle cells and ova. The epithelial pro- 
longations which grow out of the Wolffian body into the ovary, and which 
penetrate the ovary, are so-called "sexual bands" of the primary 
kidney. They originate from the epithelium of the Malpighian bodies, 
and extend toward the tubes of Pfliiger. From the latter develops the 
cortex of the ovary ; the former take part in the formation of the medul- 
lary portion and are called "medullary bands." 

According to Nagel, those connective-tissue cells which divide the ger- 
minal glands into compartments originate froln the stroma of the Wolff- 
ian body, without participation of the Wolffian canals. 

Duct of Gartner.— The Wolffian ducts, if retained, would lie 



182 



DUCT OF GARTNER. 



in the fornix and the upper lateral wall of the vagina, and not in the 
anterior vaginal wall. The Wolffian duct becomes the duct of Gartner, 
and ijs sometimes present in the wall of the uterus and in the fornix. 
Nagel says it extends as far as the vaginal portion of the cervix. Beigel 
and Dohrn have found it along the vagina. Ackermann has followed it 
down to the hymen. Klein .followed it, in the newly-born, from the 
parovarium into the uterus and to the wall of the cervix. On the other 
side it extended from the parovarium to the broad ligament, into the body 
of the uterus and into the cervix wall, where it took an S-shaped curve 
through the fornix and along the vagina. Branches of the duct of 
Gartner are often given off into the uterine substance. 

Parovarium. 

Epoopkordn.—On the development of the kidney the "Wolffian body 
retrogrades. The upper or ''sexual part" (epoophoron) is usually re- 



Ostium abdom 
Wolfflan body 

Lateral l}ody wall 
Tube 



Ovarium 



Mesovarium 



Lig. teres, ut ... , '^^^ '' '"" ^^^""^^ 

Proc. vag. per it. ' " 

Figure 98. — Tube^ Uterus^ and Ovary of the Right Side at the Beginning of the 

Third Month. (Kollmann.) 

tained, and in the late fetal period suffers little change of location. In the 
newly-born it is often atrophied. It lies in the mesovarium and meso- 
salpinx, between the ovary and the tube, with variations in the size and 
number of its tubules. The tubules run into the duct of Gartner, which 
lies parallel to the Fallopian tube and at right angles to the tubules. In 
the epoophoron are found pseudoglomeruli, which are not regressive ones, 
but immature later formations in the fetal period. This is evidenced by 
the fact that the epithelium of these glomeruli is well preserved. In the 
tubules is found ciliated epithelium, and their walls contain smooth 
muscle fibres. The tubules usually end blindly at the hilus, but may 
extend into the ovary even up to its surface. It is to be mentioned that 
during its development the epoophoron is not situated very near the 
duct of Miiller. 

Paroophoron. — The paroophoron, or yellow body of Waldeyer, is what 
remains of the lower distal portion of the Wolffian body. Malpighian 



PAROVARIUM. 



183 



bodies are still found in the fourth intrauterine month, but rarely in 
adults. According to Waldeyer, the paroophoron is found in adults in the 
broad ligament medial to the epoophoron and often extending up to the 
uterus. It is composed of small, round or long bodies which are blind 
tubules filled with epithelial cells, cell detritus, and pigment, giving this 
structure a brownish or yellowish color. The tubules anastomose fre- 
quently. The paroophoron is more rarely found than is the epoophoron. 
Aschoff believes the paroophoron of Waldeyer to be the continuation 
of the proximal or "sexual portion" of the AA^olffian body, instead of rep- 
resenting the distal or secreting portion. He finds the latter, after descent 
of the ovary, below and lateral to the epoophoron. Meyer finds the par- 
oophoron in the fetus of two or three months to be on the posterior ab- 
dominal wall, to the right and left of the vertebrEe, and lateral and an- 



Append 

vesicul 

Morgagni 

Fim'bria 
ovarica 




Duct of 

Mueller 

Parovarian 

remains 
Parovarium 

(Epoophoron) 



Paroophoron 



Duct of 

Mueller 



..- Uterus 
— Duct of 



Gartner 

FiGUEE 99. — Relatiok or the Wolffian Duct and the Duct of Mueelee in the Female 

Embeyo. (Schematic after Kollmann.) 



terior to the uterus. It is situated in a peritoneal fold which goes over 
into the- broad ligament. On descent of the adnexa the paroophoron is 
carried further and further from the posterior abdominal wall, down- 
ward and laterally into the broad ligament, according to the insertion of 
the latter. Since the base of the broad ligament in its development comes 
to lie more and more laterally, the paroophoron is also carried along, with 
the exception of such remnants as may he left more medially or on the 
posterior abdominal wall. Its situation in the mesial portion of the broad 
ligament near the uterine border is not the usual one, according to Meyer. 
Cilia are characteristic of certain areas of the parovarium. 1. Even 
in the early embryonal period the epithelium of certain areas of the 
Wolffian body tubules, and in fact those cells which are high cylindrical 



184 TESTICLE. 

at their height of development, are furnished with cilia. 2. In the newly 
born mammals, and also in adult women, cilia may be found in the re- 
mains of the Wolffian body, surely in the epoophoron. 3. The special, and 
perhaps normally the only, area of the Wolffian tubules which possesses 
cilia is the middle section. 4. The area of transition of the tubules into 
the main canal, namely, the outlets of the collecting tubules, as well as 
the main tube or Wolffian duct, are free from cilia. 5. That end of a 
primary kidney tubule which begins at the Malpighian body can be fol- 
lowed, in earliest embryonal life, beyond the capsule of Bowman up to 
its funnel-shaped beginning in the pleuroperitoneal epithelium. These 
primary kidney funnels have not been positively found to contain cilia. 

Testicle. — In man the testicle receives its specific tissue elements di- 
rectly from the germinal epithelium, which furnishes the primary seminal 
cells. The tubules which grow from the primary kidney into the testicu- 
lar formation (the sexual bands) furnish an outlet to the semen. There- 
fore the seminal tubules, tubuli seminiferi, originate from the germinal 
epithelium, while the tubuli recti and rete testis originate from the 
primary kidney or Wolffian body. The cephalic portion of the Wolffian 
body forms, in addition to the tubuli recti and rete testis, the epididymis, 
i.e., the head of the epididymis ; the tail of the epididymis is formed from 
the beginning portion of the vas deferens. The entire vas deferens is 
formed by the Wolffian duct. 

The lower end of the primary kidney (paroophoron in the female) dis- 
appears. There are found for a long time in older embryos, between the 
vas deferens and the testicle, small twisting tubules, between which dis- 
appearing Malpighian bodies occur, and the whole forms a small yellow 
body. In adults the remains are quite small, forming the vasa aberrantia 
of the epididymis and the paradidymis of Giraldes. 

The ducts of Miiller disappear almost entirely in the male, but are 
present during embryonal life as epithelial strands. The lower ends of 
the ducts of Miiller form the uterus masculinus. The separating wall 
disappears and they unite into a small tube which lies between the outlet 
of the vasa deferentia and the prostate. They are called "sinus prosta- 
ticus" and correspond to the vagina. 

The upper end of the duct of Miiller may form hydatids, small vesi- 
cles which are found upon the epididymis and are lined with ciliated cyl- 
indrical epithelium, and which may continue into a small ciliated duct. 
At one point they may possess a cyst-like opening. The anterior end of 
the duct of Miiller possibly disappears in the female, and the permanent 
opening probably develops anew. 

Just as, in the male, the epididymis tubules from the Wolffian body 
grow into the substance of the testicle and form the rete testis and the 
tubuli recti, so, in the female, tubules may pass out from the parovarium 
into the medullary substance of the ovary, and this condition is not un- 
commonly found in the adult. 



PAROVARIxVN RESTS. 185 

Parovarian Rests. 

Parovarian remnants are fonnd, as a rule, on the anterior layer of 
the broad ligament above the enclosed parovarium, for the various parts 
of that ligament come from portions of the AA^olffian body, and the 
celom epithelium of the Wolffian body becomes the peritoneum of the 
broad ligament. There are also found funnel-shaped pedunculated 
growths with their openings toward the abdominal cavity and fur- 
nished with ciliated epithelium. Two funnel-shaped openings with 
one pedicle also occur. Cystic renmants corresponding in position, 
size, and form are also found, but in place of the funnel-shaped opening 
a cyst is present which is always lined with ciliated epithelium. 

. Grape-like growths may be present. In structure they are like the 
above-mentioned form, but at the free edge is found a dilatation lined 
with ciliated epithelium. 

The tubo-paroN^arian canal is a rudimentary canal passing off from 
the parovarium and lined with ciliated epithelium, which opens into the 
end portion of the tube, or more frequently upon the fimbria ovarica. 
A similar canal is found which does not open on the fimbria ovarica. It 
may be considered as a remnant of the "Wolffian duct. 

At the opening of the tube there is often found a cystic vesicle, a 
hydatid of Morgagni. It is a question whether it belongs to the tubules 
of the Wolffian body or comes from the anterior end of the duct of 
Miiller. In the disappearance of the very first formation of the latter 
such a hydatid might be formed, but then a new tube opening would 
have to be created. 

Nagel says that the main canal of the parovarium runs parallel to the 
tube, and that it ends blindly at its upper end, at times in a small cyst, 
the hydatid of IMorgagni ; that toward the median line it may be fol- 
lowed as the duct of Gartner up to the uterus. We have already men- 
tioned that remains of it are found in the lateral walls of the body of the 
uterus and of the cervix, and rarely, perhaps, in the upper part of the 
vagina or even down to the hymen. 

All these show a remarkable resemblance to the funnel-shaped rem- 
nants and the pedunculated hydatids found in the epididymis. These, 
too, are probably the remains of the multiple segmental communications 
between the AVolffian body and the celom through the medium of tubules. 

I. GROWTHS ORIGINATING FROM THE PAROVARIUM 

(EPOOPHORON). 

(a) Normal Anatomy. 

The tubules of the Wolffian body have small branches, i.e., microscopi- 
cal lateral sprouts, which remain enclosed in the fibrous tunica propria 
of the tubules. The same are found in the organ of Giraldes. The 
tubules have large dichotomous branches, and lateral sprouts at the 



186 EPOOPirORAL GROWTHS. 

blind end of the parovarian tubules. The same are present in the organ 
of Giraldes. The tubules of the epoophoron are arranged in parallel 
order, like the teeth of a comb. 

These characteristics are present in the small and large cysts originat- 
ing from the parovarium. 

(b) Pathological Anatomy. 

(ct) Small Parovarian Cysts. 

These are situated at the normal location of the parovarium. They 
are lined with low epithelium and possess cylindrical ducts. Around 
them are found, microscopically, tubules lined with a low epithelium, 
which are twisted, varicose, branching, or with many dilatations or am- 
pullae and small diverticula. The ends of the tubules are frequently 
dilated and form cysts. Other tubules are lined with a ciliated, cylindri- 
cal epithelium. "With other small parovarian cysts are found minute 
areas of a glandular character. These little cysts may form a continuous 
chain even up to the lateral wall of the uterus. The individual cysts 
are then usually of the size of a pin's head. Polycystomata of the epoo- 
phoron of a diameter of fifteen to twenty millimetres may be found. 

These various structures have been followed in direct continuity -with 
uterine adenomyomata v. Recklinghausen, proving both to have devel- 
oped from a common formation. In these small cysts pigment bodies may 
be present. In rare instances muscle fibres are found in their walls. 
These are usually attributed to the muscle fibres present in the broad liga- 
ment. It must not be overlooked that the parovarian tubules contain 
muscle fibres in their walls. The characteristics of these little cysts are a 
firm, fibrous wall, diverticular projections, accessory cysts, and a connec- 
tion with parovarian tubules. 

They are to be distinguished from lymph cysts and cysts of the serosa, 
both of which are lined with endothelium or a flat epithelium. 

(p) Large Parovarian Cysts. 

These may contain a quart or more of a clear, thin fluid, but are 
seldom larger than a child's head. They are intraligamentous, thin- 
walled, and lined in part with ciliated epithelium. They may contain 
a stained fluid and pigment bodies. The ovary, while usually not af- 
fected, is frequently stretched and flattened by these cysts. 

Kossmann believes that most of these tumors are hydroparasalpinges. 
He believes that they are the result of more or less well-developed ac- 
cessory tubes, especially since muscle fibres may be present in their walls, 
and because of the projections which may be found on their inner 
surface. 

Accessory tubes have been found in the embryo by Nagel and several 
times in the sheep by Amann. 

Gebhard has shown that the tubules of the epoophoron possess a 



EPOOPHORAL GROWTHS. 187 

muscularis. The muscle fibres which may be found in the wall of paro- 
varian cysts are the result of this muscularis, or else they originate from 
the muscle fibres normally present in the broad ligament. By no means 
do all parovarian cysts possess a more or less muscular wall, which should 
be the case if these were developed from accessory tubes. 

The projections on the inner surface may resemble the intestinal 
giands of Lieberkiihn. These and other projections are considered by v. 
Recklinghausen to develop from the branches, diverticula, and lateral 
sprouts of the parovarian tubules, v. Recklinghausen has followed in 
serial sections the direct entrance of parovarian tubules into a large paro- 
varian cyst. Klob has done the same, and Peters found this frequently in 
the smaller cysts, so that their origin from the parovarium (epoophoron) 
is beyond question. 

yX) Adenomata and Fibroadenoniata of tlie Epooplioron. 

Switalski, in examining serial sections of the epoophoron in the fetus 
and newly-born, not infrequently found cystic formations. Minute cysts 
originating from these tubules were found also in the wall of a Fallopian 
tube, and even in the fimbria. In the mesovarium were found epithelial 
structures of the character of an adenoma. 

Adenomata of the epoophoron are rare. They originate from and in 
the normal situation of the epoophoron. They show macroscopically and 
microscopically the type characteristic of the uterine adenomyomata of 
V. Recklinghausen. They show main tubules, collecting tubules, secreting 
tubules, etc. The glands are lined with simple, large cylindrical cells, 
often showing cilia. In addition, other glands may be present like those 
found in chronic hyperplastic endometritis. The glands divide dichoto- 
mously and give off cystic dilatations. This varying character of the 
glands is an evidence that the typical structure of the Wolffian body is 
not necessarily reproduced in tumors resulting from the epoophoron. 
Pseudoglomeruli are also found, as well as pigment. Since these two 
are present also in tumors originating from the paroophoron, a sharp dis- 
tinction between the two divisions of the parovarium cannot always be 
drawn. Pick described a bilateral adenoma of the epoophoron. One con- 
tained muscle fibres and much cytogenic tissue, really constituting a 
fibroadenoma. 

(^) Mesonepliritic Adenomata of the Ovary. 

It is an interesting fact that just as the tubules of the "Wolffian body 
enter into the testicle, forming the tubuli recti and rete testis, so do they 
enter into the ovary, but not as functionating tubules. 

In the fox and in the newly-born female these tubules pass as the 
"medullary strands" enveloped in a mantle of connective tissue, from the 
hilus into the ovary and even up to the periphery. This " Grundstrang" 
is present in every ovary. 



188 EPOOPHORAL GROWTHS. 

V. Franqiie found, in a 20-year-old female, spaces in the ovary origin- 
ating from the Wolffian body tubules. In an adenomyoma of the uterus 
and tube wall. Wolffian body structures have been traced in the ovary 
into the parenchymatous layer. An elaborate system of gland tubules 
and cysts has been traced from the hilus up to the ovary in a woman 
54 years old. The cysts were arranged like those found in the adenomy- 
omata of v. Recklinghausen, an especial characteristic being their ten- 
dency to dichotomous division. 

In adenomata of the ovary originating from the Wolffian body tubules, 
we have not only cysts but adenomatous products and cytogenic tissue. 
The character of the cells and the arrangement of the tubules is char- 
acteristic of the tumors of v. Recklinghausen. We find tubules into which 
several parallel ducts empty on one side. These may be dilated at their 
free end. The whole form is arranged like the teeth of a comb, and such 
groups represent the structure of a diminutive epoophoron. In addition, 
systems of tubules showing continuous dichotomous division are present. 
In these adenomata muscle fibres may be present. These are supposed to 
result from the muscle cells normally present in the ovary. It is quite 
possible, however, that they result from the muscular layers of the paro- 
varian tubules. Kehrer described a multilocular ovarian cystoma whose 
wall contained numerous muscle fibres arranged about a system of tu- 
bules and about glands lined with ciliated epithelium. Myxomatous 
tissue was present in abundance. This tumor presents a proliferating 
glandular cystoma combined with a paroophoral cystadeno-fibromyoma. 
A cystic tumor was also found in the inguinal region just outside the 
external inguinal ring. 

Small adenomyomata, as well as the small adenomata of the ovary, 
may present glands resembling decidedly in structure the uterine glands. 
For this reason, in some instances, their origin has been attributed to 
cells of the ducts of Miiller. From a study of our embryological review 
it may be seen that such an aberration is impossible. 

{£) Mesonephritic Cystomata of the Ovary (Ovarian Cysts'). 

(a) Simple Serous Cystoma. — These cysts are usually of the size of a 
child's head, usually pedunculated, yet often intraligamentous. They 
contain a clear fluid. The inner surface is usually lined with simple 
cylindrical epithelium. They are usually free from proliferating glandu- 
lar structures, but not infrequently show papillary growths. 

(h) Papillary Serous Cystadenoma. — These are often bilateral. The 
contents are serous in character. In many cases ciliated epithelium is 
found, in other cases none. 

(c) Glandular or Papillary Pseudomucinous Cystadenoma. — The con- 
tents are a thick mucoid substance. The walls show depressions micro- 
scopically resembling the glands of Lieberkiihn. These are lined with 
cylindrical epithelium containing very numerous beaker-like cells. The 



EPOOPHORAL GROWTHS. 189 

papillary form is characterized by the presence of papillary excrescences 
covered by the same form of epithelium. 

(d) Surface Papilloma. 

(e) Grape-like Cysts which represent a transition form from h and 
c to e. 

The origin of these growths has been variously referred to the epithe- 
lium of the follicles and to the germinal epithelium covering the surface 
of the ovary. It is impossible for the follicle epithelium to be the source 
of origin, for the membrana granulosa degenerates on destruction of the 
ovum. No one has yet observed the transition of a follicle or its epithe- 
lium into the above-mentioned growths. 

The same forms of cysts occur in the male, resulting from the tubules 
of the testicle or from the organ of Giraldes. Since these tubules are 
found in the ovary, there is no question that they are the cause of the 
above-mentioned growths. 

It is impossible that the germinal epithelium could produce such 
cysts, for these tumors are situated in the ovary and not so rarely intra- 
ligamentous. Even with smaller cystomata the ovarian tissue has almost 
disappeared, a condition not satisfactorily explained by attributing their 
origin to germinal epithelium. This fact can only be explained when we 
understand that the tubules entering from the hilus develop in all 
directions, and in this way involve the entire ovary. A proof of the 
origin of papilloma of the ovary from these tubules is seen in the fact 
that, in different areas of these papillomata, cysts or remnants of a cyst 
wall are found whose inner surface shows numerous papillary excres- 
cences. This shows them to be papillary cystomata which have opened 
through and developed upon the ovarian surface. 

The other forms of cystic changes in the ovary are hydrops folliculi 
and corpus-luteum cysts, neither of which are in genetic relation to the 
Wolffian body tubules. 

II. GROWTHS RESULTING FROM THE PAROOPHORON AND 
FROM DISPLACED REMNANTS OF THE WOLFFIAN BODY. 

(a) Normal Anatomy. 

An important question in proving the origin of growths from dis- 
placed remnants of the Wolffian body depends upon proving the possi- 
bility of such a displacement. Has the displacement of the Wolffian 
body cells been proved by examinations in the fetus? 

Robert Meyer examined in serial sections the uteri and appendages 
of 100 fetuses, newly-born children, and older infants, v. Recklinghausen 
has done the same. Neither could find characteristic elements of the 
Wolffian body, especially in the walls of the uterus and tubes. Meyer 
found, however, some glands in the myometrium whose epithelium dif- 
fered from that of the uterine mucosa, and one cystic gland resembling 



190 PAROOPHORAL GROWTHS. 

the secreting portion of a Wolffian tnbnle. He believes that it will be 
impossible in this way to show a connection between epithelial inclusions 
and the Wolffian body, because such displacements naturally occur in 
very early embryonal life, when the differentiation of its cells has not 
yet taken place. There occurs, then, no displacement of glands of the 
Wolffian body or parts of the Wolffian duct, but only a transplantation 
of cells which are later on able to develop into glands and tubules, espe- 
cially at puberty when the changes and stimulations of that period 
bring such cells to active development. 

In determining the origin of tumors from displaced remnants of the 
paroophoron, it is important to make a comparison between the latter and 
the paradidymis or organ of Giraldes. The paroophoron is the so-called 
''yellow body." Although the glomeruli disappear after the fourth 
month, regressive glomeruli or pseudoglomeruli may be found. The 
tubules are of two kinds — 1, twisted (secretory), and 2, straight (collect- 
ing tubule) — and possess ampullae, v. Reckinghausen found in the tubal 
angles isolated glands which he considers to be remnants of the Wolffian 
body. Rieder found groups of cylindrical cells in the broad ligament 
near the lateral border of the uterus with remains of the Wolffian 
duct, and considers them to be remnants of the Wolffian body (paroopho- 
ron). Ricker found a yellow body of glandular structure in the same 
location under the serosa. The tubules were arranged in parallel 
ORDER and were both straight and twisted. 

In the same relative situation is found the paradidymis of the male, 
or the organ of Giraldes. It furnishes the vasa aberrantia of the testicle. 
The tubules contain cilia, but not on the flat epithelium of the glomerulus 
capsule. Though usually separated, they may be connected with the 
vasa efferentia (sexual part of Wolffian body). If so connected, they 
may give rise to extravaginal spermatocele. Kocher was able to inject 
mercury from the vas deferens into such a spermatocele, and the reverse 
has also been done. Injections into hydatids situated at the head of the 
epididymis have passed into the tubules of the epididymis, proving the 
former to originate from the Wolffian body tubules. 

The cystomata and cystadenomata of the epididymis and testicle de- 
velop in all probability from the organ of Giraldes. The characteristics 
of such cysts are: 1, simple epithelium; 2, ciliated epithelium; 3, a 
cylindrical or cuboidal form of the cells. 

The same characteristics in these and other particulars are found in 
the tumors mentioned below, especially in those adenomata and adeno- 
myomata of the uterus and tube angles which v. Recklinghausen refers 
for their origin to the AYolffian body i.e., to the distal end or paroo- 
phoron. It may be mentioned that with those tumors v. Recklinghausen 
found other glands and cysts in the myometrium, undoubtedly originating 
from the uterine mucosa. • These, however, did not contain ciliated epi- 
thelium. . . - 



PAROOPHORAL GROWTHS. 191 

The situation of certain glandular tumors in areas where glands ar6 
normally absent makes their origin from cells of the "Wolffian body posi- 
tive, inasmuch as embryological conditions favoring displacement are 
present. Therefore, even though the resulting glandular structures do 
not decidedly resemble those of the Wolffian body, their location is 
abundant proof. 

Displacement of Wolffian Body Cells. 

A. The inguinal band, which is first attached to the Wolffian duct 
and later to the duct of Miiller, becomes the gubernaculum Hunteri, and 
finally the ligamentum teres. In this way rests of the Wolffian body 
may be carried into the uterine wall, into the inguinal region, or even up 
to the labia major a. 

B. Through the change of position due to the development of the 
broad ligament, rests of the paroophoron may be left in it at various 
points. 

C. Cells of the A¥olffian body may be carried into the region of the 
cervix by the vasa spermatica, which anastomose with the vasa uterina, 
or by the duct of Gartner. 

D. Some of the cells of the Wolffian body may be left on the posterior 
abdominal wall. 

E. Through the spiral twist of the ducts of Miiller and the distal, 
continuation of the Wolffian body, the dorsal side of the uterine portion 
of each duct of ]\Iiiller lies upon the lower end of the Wolffian body and 
may take up some of its cells. 

(b) Pathological Anatomy. 

Ad A. (tl) ribroadenoma of the Iiigamentum Teres. 

The cystic tumors of the round ligament are either hematomata or 
else constitute a hydrocele (canal of N'uck). The solid tumors are either 
sarcoma, sarcoadenoma, or cystofibroma. The latter may be situated in 
the round ligament within the abdomen, subcutaneously and external to 
the inguinal ring, or Avithin the inguinal ring, breaking through all the 
tissues of the abdominal wall. In adenomata of the round ligaments may 
be found muscle tissue, and certainly fibrous connective tissue. Islands 
of glands and cysts are present. The glands show prominences made up 
of cytogenic tissue, which are called "pseudoglomeruli." The epithe- 
lium is simple, cuboidal, or cylindrical, but may be flat like endothelium. 
The cysts and ampuUge are filled with blood, pigment, red blood cells, leu- 
cocytes, cell detritus, or hyaline substance. They show the characteristics 
of V. Eecklinghausen's a;denomyomata, to be mentioned later. 

Although these glandular structures do not always decidedly re- 
semble in form and structure the Wolffian tubules, yet they undoubtedly 
originate from epithelial cells of this organ. In some cases the glands 



192 PAROOPHORAL GROWTHS. 

bear a decided resemblance to those of the uterine mucosa. It must be 
mentioned that adenomata of the epoophoron itself contain glands lined 
with simple cylindrical epithelium, often ciliated, while other glands 
are present resembling those found in hyperplastic endometritis. 

The inguinal band is connected only superficially with the duct of 
Miiller, and as the epithelium of the latter is not near the surface none 
of its cells can be carried along. The glands of the Wolffian body, how- 
ever, are connected with the celom epithelium, and thus some of their 
cells may be transplanted by the inguinal band to any point of the sub- 
sequent situation of the ligamentum teres. 

Ad B. (/3) Parooplioral Cysts of the Broad. liigament. 

Such cysts may be present in the various parts of the broad ligament 
and yet the ovary and the epoophoron are present. Cysts originating 
from the epoophoron usually contain a clear fluid, are thin-walled and 
lined with cubical, cylindrical, and also ciliated epithelium. Cysts orig- 
inating from the paroophoron, because of the pigment characteristic 
of this portion of the Wolffian body, usually contain a brownish fluid 
and pigment in the cellular tissue of the wall. They are lined with 
cubical or cylindrical epithelium, and cilia may be found in the cells of 
the wall or in cells of the contents. The latter contains large pigment 
bodies with a pigmented protoplasm and dark brown nucleus. They 
are usually situated near the lateral border of the uterus. 

(y) Cystomyomata of the Broad ILigameiit. 

Such tumors not connected with the uterus have frequently been 
explained as being tumors originating in the uterus and connected with 
it by a pedicle. On the disappearance of the pedicle the tumor was con- 
sidered, therefore, to have originated from the uterine structure. 

Other tumors of this character have been considered as developing 
from the muscular tissue in the broad ligament, and the cystic areas have 
been attributed to softening and degeneration, or to dilatation of lymph 
spaces or tissue spaces. Even though most previous descriptions have 
made but rare mention of the presence of glands, close examination 
would probably find such to be present in many instances, if not in all. 
If such glands are present, their origin must be attributed to cells or 
rests of the Wolffian body, namely, of the distal portion, the paroophoron. 
It has already been mentioned that in descent of the adnexa, and the 
change of position and development of the broad ligament, such cells and 
rests may be carried along. These tumors have been found to contain 
ciliated epithelium and a brownish, thick fluid, The primary tumors 
of the broad ligament (desmoid tumors) include also sarcoma, cysto- 
sarcoma, chondrosarcoma, etc. It is perfectly possible that these have 
developed from mesodermal cells displaced into the broad ligament by 
the inguinal band or by the paroophoron. In that event the glandular 



PAROOPHORAL GROWTHS. 198 

elements have either not been found or have disappeared, or else meso- 
dermal cells alone have been displaced (see Cytogenic Tissue). 

Ad C. {^ ) .\<lenoniata and Fibromata of tlie Cervix. 

Such tumors have been found on the dorsum of the cervix and in the 
posterior fornix. In the lateral wall of the cervix they may result 
from the root-like extensions of the duct of Giartner, or from rests of 
the Wolffian body displaced by the duct of Gartner or by the vasa 
spermatica. Fibromyomata in the posterior fornix extending from the 
muscle wall of the vagina into the paravaginal tissue have been described. 
If glands are present in such tumors they constitute adenomyomata. A 
situation on the dorsum of the cervix speaks in favor of an origin from 
rests of the Wolffian body. A characteristic of fornical adenomyomata 
is the dichotomous division of the tubules. 

Ad D. {s > Adenomata and Cystadenomata of tlie Posterior Abdominal TVall* 

In the descent of the parovarium from the posterior abdominal wall 
into the broad ligament elements may be left behind giving rise later to 
pathological growths. Hartz described a cystadenoma on the posterior 
abdominal wall containing cysts and glands with the characteristic struc- 
ture of the Wolffian body tubules as well as glomeruli. The genitalia 
were entirely intact and the growth was not possibly related to the duct 
of Miiller. Although undoubtedly a derivative of the Wolffian body or 
its cells, many of the glands and cysts bore no resemblance to the tubules 
of the mesonephros. Cytogenic tissue was present in large amount. 

Ad E. (-jl Glands and Cysts in the IVIyometrinm. 

Deep branches of the mucosa frequently extend into the muscular 
wall of the fundus of the uterus and the tubal corners. With adenom- 
ata such glands and cysts in the myometrium may be separated parts 
of the same. If not situated far from the mucosa they are to be con- 
sidered as post-fetal growths of the latter. If, however, they are sit- 
uated far from the mucosa or near the serosa, they are to be viewed 
as congenital displacements either of cells of the duct of Miiller or 
of cells of the Wolffian body. A positive distinction cannot be made 
from their form and structure. Pick found in the external muscle 
layers of the posterior wall of the uterus small numbers of isolated 
scattered glands, not connected with the mucosa. Because of the pres- 
ence of a typical lymphadenoid stroma, he believes them to have orig- 
inated from cells of the ducts of Miiller (see Cytogenic Tissue). 

(f/) Subserous Glands of the Uterus. 

These occur more frequently than is generally known. They are 
situated, as a rule, anteriorly or posteriorly, or both, and never laterally. 
13 



194 PAROOPHORAL GROWTHS. 

They are found, as a rule, in the lower part of the uterus, and are lined 
with an epithelium almost like endothelium. They generally occur 
in the subserous longitudinal muscle layer. As to their origin various 
possibilities are to be taken into consideration: 

1. Displaced cells of the ducts of Miiller. Since these glands are 
usually subserous and often communicate with the peritoneum, such 
an origin is not probahle. 

2. A post-fetal origin from the mucosa is improbable because of 
their situation. 

3. An origin from the serous membrane itself, either congenital or 
acquired, especially the latter, is probable because such glands are not 
found in the fetus, and probably develop later with peritoneal irritation. 
Meyer believes that the endothelium of the serosa changing to epithelium 
is the cause of most of these glands. Since a change of serosa to ciliated 
epithelium has not yet been observed, this view is probably incorrect 
for all cysts or glands lined mth anything but endothelium, and dis- 
placed cells of the Wolffian body are the most probable cause. This is 
especially probable if the glands show a papillary structure and club- 
shaped epithelium. Cells of the Wolffian body or of the germinal epithe- 
lium may be displaced into the serosa and develop later. Pick described a 
cystadenoma of the ovary with a ciliated cyst containing glands on 
the parietal peritoneum. Papillary excrescences were likewise found. 
Since the same structures were found in the subserosa, the Wolffian 
body or its cells are the probable source of origin of the entire group. 
The situation of such glands speaks against their origin from the duct 
of Gartner, for the latter is situated in the lateral border of the peri- 
metrium or uterus. With malignant adenoma of the uterus it is pos- 
sible that such glands may be present in the serosa as metastases. 

(3^) Retrouterine Subperitoneal Cystomata. 

• 

Pfannenstiel described subserous cysts lined with simple ciliated 
epithelium and situated on the posterior wall of the uterus. On the 
lateral wall were several small cysts, also lined with ciliated epithelium. 
V. Eecklinghausen found in conjunction with adenomyomata of the 
uterus polycystomata in the sac of Douglas and small subserous cysts 
on the fundus. Their structure brings them into the class of adenocyst- 
omata. A case of Doderlein's was composed of cysts of the character of 
ovarian cystomata with papillary excrescences. In addition was found 
a hard appendage composed of smooth muscle fibres. 

Kronig described a polycystoma originating in the uterus and grow- 
ing into the sac of Douglas and extending up to the umbilicus. Both 
adnexa were normal, as were also the broad ligaments. The area at the 
base of Douglas' cul-de-sac had the structure of a cystic adenomyoma 
with an arrangement of glands typical of the tumors of v. Eeckling- 
hausen. Pigment, hemorrhages, and pseudoglomeruli were present, 



PAROOPHORAL GROWTHS. 195 

making the diagnosis one of paroophoral myoma. The cystic portions 
were made np of glands and cysts lined with simple cylindrical epithe- 
lium and contained a brownish-red fluid. Numerous muscle fibres were 
present in the wall of the cystoma. 

{i) Adenomata of the Tubal Angles. 

That portion of the tubal canal which lies in the uterine wall is 
called ' ' pars uterina. ' ' The greater portion of the pars uterina towards 
the fundus uteri has glands in its mucosa and really belongs to the uterus, 
being called the ' ' tubal corner. ' ' The really interstitial part of the tube 
possesses its own muscularis and has no glands in the mucosa, and is 
called the "tubal angle." In the tubal corners a congenital branching 
of the mucosa is frequent, and the majority of adenomatous areas are 
probably acquired, occurring in the tubal corners more frequently 
than in the myometrium. 

In the "tubal angles," however, adenomata appear usually in the 
external layers, but may be found in all layers of the muscularis. They 
may communicate with the lumen, but rarely with the serosa. The 
glands may be found scattered or closely grouped, usually scattered. 
There is often found a "system" of tubules entering into a central 
reservoir called the "ampulla." The tubules are lined with simple 
cylindrical epithelium, the cells and nuclei being arranged in even line. 
The ampullae have a high epithelium on the floor and a low epithelium 
on their roof. These adenomata often communicate with the mucosa. 
The epithelium, however, which lines the communicating tubules is quit& 
different from that of the mucosa, for the latter may be arranged in two- 
layers and the nuclei and cells form an irregular line. Although the 
mucosa of the tubal angles may be the source of adenomata, the charac-^ 
teristic structure of the large number of adenomata of the interstitial 
portion, and the character of the epithelium lining the tubules communi- 
cating with the mucosa, make the origin of such adenomata from the 
Wolffian body highly probable. 

(%) Adenomyomata of the Uterus and Tubal Angles. 

In adenomyomata of the uterus and tube, whose origin he refers to 
displaced cells of the Wolffian body, v. Recklinghausen distinguishes 
(1) the larger forms, which are found in all layers of the myometrium, 
and (2) the smaller ones, which are found especially in the peripheral 
layers of the uterus and the tube. In contradistinction to other myomata 
which are well outlined and can be frequently shelled out, these adeno- 
myomata are characterized by their tendency to infiltrate the surround- 
ing tissue. V. Recklinghausen distinguishes the following forms in the 
uterus : 1. The hard form, mth more muscle than adenomatous tissue. 
These are generally situated in the peripheral part of the uterus. 
2. The cystic form, with macroscopic spaces and cysts. 3. The softer 



19f) PAROOPHORAL GROWTHS. 

form, with much adenomatous tissue, and islands of glands embedded 
in cytogenic tissue. 4. The softest form, with vascular and almost 
cystless adenomatous tissue, the so-called '^ angiomatous form." 

These adenomata of the corpus uteri are almost always found on the 
dorsal wall. They grow ( 1 ) from isolated centres, forming large masses, 
generally in the periphery, or (2) from numerous centres, extending 
therefore in the various layers of the muscular wall. 

Such adenomyomata are to be distinguished from myomata containing 
cysts due to softening of myomatous tissue, or to a dilatation of tissue 
spaces, or to a dilatation of lymph vessels, in which event they are lined 
with endothelium. 

The glands in these tumors of the uterus are usually "closely 
grouped." The myomatous portion of the tumor seems then to grow 
independently of the glandular, and the individual tubules of tlie 
glands have no muscle boundary. Yet the myomatous elements some- 
what distinctly outline the adenomyoma from the surrounding tissue. 
There is often, in addition, a real hypertrophy of the entire myometrium, 
due probably to the stimulations of puberty, which make such an hyper- 
trophy independent of the stimulation due to the adenomatous for- 
mation. In all the tumors described by v. Recklinghausen the patients 
were over twenty years of age. Large tumors with much muscle tissue 
were found in women up to the fifty-sixth year; none were found in 
recently gravid uteri. 

In the smaller tumors of the uterus, especially if the glands are 
' ' scattered, ' ' the muscular constituents grow hand in hand with, and pro- 
portional to, the adenomatous growth and about the individual ducts. 

The majority of the adenomyomata of the tube are bilateral and occur 
usually in the tubal angles, v. Recklinghausen finds them on the dorsal 
wall and on the cranial side of the interstitial portion, but sometimes 
about the tube. They are of two forms, (1) the hard form, with a close 
grouping of fibrous and muscular tissue and the presence of tense cysts ; 
(2) the soft form, which has a red appearance on account of the 
numerous blood vessels, and which is almost angiomatous. The hard 
form contains very little cytogenic tissue, but the soft form contains 
relatively much more. The glands are usually arranged in "scattered" 
order and evidence a decided tendency to the formation of cysts. The 
•cysts are branched, sending out ducts lined with a somewhat higher cylin- 
drical epithelium. The muscle fibres form a boundary about the indi- 
vidual tubules, in a longitudinal direction, and their growth goes hand 
in hand with, and proportional to, the development of the adenomatous 
areas. The same is true of those tumors of the uterine wall which are 
small and contain "scattered" glands. These adenomyomata are more 
frequent in the tubal angles than in the uterus. 

The characteristic element in these adenomyomata is furnished by 
glands lined with simple cylindrical (ciliated) epithelium. In this 



PAROOPHORAL GROWTHS. 197 

respect they resemble the Wolffian body. Ciliated epithelium is normally 
present in the Wolffian body tubnles, and in many growths resulting 
from them, such as (1) cystomata and cystic fibromata in the hilus of 
the ovary, (2) parovarian cysts and ovarian cystomata genetically 
related to the Wolffian body, (3) cystic myofibromata in the broad 
ligament, (4) cysts and parovarian rests in the ala vespertilionis^ 
(5) paroophoral cysts, (6) subserous and retrouterine adeno-cysts, 
(7) like growths of the organ of Giraldes. Cilia have been found in 
the adenomyoma of an eighty- two-year-old patient. 

V. Recklinghausen distinguishes in these tumors (1) narrow tubules 
lined with a high epithelium, called "collecting tubules"; (2) wide 
twisting ducts with a lower pale cylindrical epithelium, called ' ^ secreting 
tubules"; (3) wide, blind ends lined Avith a flat epithelium; (4) dilata- 
tions called ' 'ampullae," which are divided into (a) main or large 
ampulla?, into which empty the collecting tubules in parallel order like 
a comb, and always on one side, (I)) ampullie at the end of a tubule, and 
(c) ampullae in the course of a tubule. 

In this respect they resemble the Wolffian body. The tubules of the 
Wolffian body have dichotomous branches, and lateral branches are 
found in the blind ends of the parovarian tubules and in the organ of 
Giraldes. In the parovarian tubules of the adult woman are found 
microscopically short, lateral sprouts which remain enclosed in the 
fibrous tunica propria of the tubules. It is from these that the small 
and large dilatations at the ends of the tubules and in the course of 
the tubules develop in these tumors. In every microscopical group of 
gland ducts in these tumors the comb form is a characteristic. In this 
respect there is a further resemblance to the AA^olffian body or par- 
ovarium. 

While resembling in these details the parovarium, their origin is 
attributed to the distal end, or paroophoron, because of the presence 
(1) of pseudoglomeruli and (2) of pigment bodies. The pseudO' 
glomeruli are round or semicircular elevations of cytogenic tissue in the 
ampullae. They differ, however, from the Malpighian bodies in that 
they contain no vessel knots and in being covered with cylindrical 
epithelium (flat epithelium in the Malpighian body). Yet their struc- 
ture, says V. Recklinghausen, proves them to be incomplete glomeruli. 
The pigment found in these adenomyomata consists of (a) large ''pig- 
ment bodies" in the lumen of the ducts, (Ij) oval or many-sided pig- 
mented cells in the tissues, (c) pigmented cells arranged in mosaic. Pig- 
ment is a characteristic of the paroophoron and the organ of Giraldes, and 
these "pigment bodies" are found in the previously mentioned cysts 
and tumors originating from the paroophoron. 

A further proof that these glands owe their origin to the paroophoron 
is found in the fact that the organ of Giraldes has branched tubules, 
various forms of cylindrical epithelium, ciliated epithelium, varicose 



198 PAROOPHORAL GROWTHS. 

dilatations of the lumina, cyst formations, pigment bodies, and glomer- 
nlus-like structures. A further proof is found in the fact that the 
adenomata and cystadenomata of the testicle, due in all probability to 
the organ of Giraldes, have the same dilated form of cysts, gland ducts 
entering into cysts, simple cylindrical epithelium, and ciliated epi- 
thelium. 

For these reasons, and because of their characteristic structure, 
V. Recklinghausen considers that these adenomyomata of the uterus and 
tubal angles result from cells or rests of the Wolffian body, especially 
of the distal end, the paroophoron. In many areas, however, the glands 
do not resemble closely the form and structure of the Wolffian body 
tubules. They differ from the latter further in that they possess no 
tunica, as is the case with the tubules of the Wolffian body and with 
Bowman's capsule. In addition the Wolffian body tubules are not 
embedded in cytogenic tissue. However, the situation of these tumors 
on the dorsal wall of the uterus and in the tubal angles is characteristic, 
and is explained by the fact that it is these parts of the ducts of Miiller 
which, in making their spiral tivist, lie with their dorsal wall upon the 
Wolffian ducts and the lower end of the Wolffian body, a condition which 
makes a displacement of cells of the latter easily possible. Further, 
near the tubal angles are inserted the round ligament, the broad liga- 
ment, and the ovarian ligament. 

It has recently been claimed that the mucosa of the uterus and tube 
is the origin of these adenomyomata. From a study of the adenomata 
of the uterus and tubal angles there is no question that in many instances 
such is the case. The difficulty is that the structure of the adenomatous 
areas is by no means always characteristic. The displaced cells of the 
Wolffian body develop years after their transplantation and must not 
necessarily form the characteristic divisions of the original Wolffian 
body tubules. We have seen that in adenomata of the posterior abdom- 
inal wall and in adenomata of the ligamentum teres, and also, as will be 
seen later in adenomata of the parovarium, the glands are by no means 
characteristic, but may frequently resemble the form and structure of 
the uterine glands. 

The important point must then be the resemblance of these adenomy- 
omata to other growths developing from 'Wolffian body cells. It is this 
fact which makes the subsequent determination of the origin of glands 
and cysts difficult and often impossible. Even the presence of cytogenic 
tissue is no absolute proof of an origin from Wolffian body tubules. 

V. Recklinghausen believes that the following characteristics speak 
for his theory: (1) The location of these tumors does not correspond 
to the entire length of the duct of Miiller or of the Wolffian body, but 
represents only that point where the duct of Miiller crosses the duct 
of Wolff. (2) The situation of these tumors is so frequently periph- 
eral. (3) Through their peripheral situation they frequently grow 



UTERINE ADENOMATA. 199 

into the subserous and parametria! tissue. (4) Even though they may 
grow toward and close to the mucosa, the ■ centres of such tumors are 
usually peripheral. (5) Such tumors are almost never found in the 
cervix. (6) The interstitial portion of the tube, which is so frequently 
the seat of these adenomyomata, possesses no glands in the mucosa. 

It must be mentioned that examinations have proved the fundus and 
tubal corners to be especially disposed to the formation of adenomata. 
A peripheral situation does not necessarily speak against a fetal dis- 
placement of cells of the ducts of Miiller. The interstitial portion of 
the tube, though possessing no glands, has nevertheless been proven to 
be the seat of adenomata of the mucosa. For these reasons, unless ade- 
nomyomata show glands quite characteristic of the Wolffian body tubules, 
their origin, in the uterus, is to be referred to the mucosa. 

In the tubal angles, however, it is probable that because of their 
frequently characteristic structure the majority of adenomyomata are 
to be referred to the AYolffian body. 

Adenomata of the Uterus and the Tubal Corners Originating from 

THE Mucosa. 

A decided growth of mucosa into the myometrium must be viewed as 
adenoma. The growths often form microscopic areas, consisting of 
hyperplastic glands with a stroma rich in spindle cells. The growth 
extends into the muscle interstices, often along the lymph channels, and 
is accompanied by connective tissue. The vessels often show hyaline 
degeneration, sometimes arteriosclerosis, and are often varicose and 
' dilated. 

The adenomatous growths are most frequently found at the fundus 
and in the tubal corners, especially in the latter. A preference is shown 
for the inner and middle muscular layers. The middle third of the 
corpus is usually less affected than the fundus. The lower third is, in 
comparison, little affected, the cervix very rarely. 

This adenomatous condition is not always in continuity, but is gener- 
ally scattered over the mucosa. Long tubules are found in the muscle 
interstices and along the lymph spaces, or else complexes are scattered 
through the muscle wall with branches and cysts. The glands at the 
periphery are often cystic. Numerous short dilatations are found at 
short intervals in the course of the tubules, giving a grape-like appear- 
ance, often pointing to beginning malignant degeneration. The cysts in 
the fundus and tubal corners are often large, giving off vesicles. The 
structure of these formations is characterized by the ahsence of any 
special system. 

The epithelium is simple high cylindrical, with irregularly placed 
nuclei. The connective tissue consists of closely grouped spindle cells, 
and their growth is usually in advance of the glands. Connected with 



200 UTERINE AND TUBAL ADENOMYOMATA. 

chronic interstitial and atrophic endometritis there is more connective 
tissue than glands. The muscle wall is but slightly hyperplastic. 

The fundus of the uterus shows a special disposition to the entrance 
of the hyperplastic mucosa into the muscle wall, and therefore to ade- 
nomata and to adenomyomata. Adenomata, as seen above, may exist in 
the myometrium without the presence or formation of myomata. The 
deeper parts of the adenomata easily become malignant, and many cases 
of adenomatous growths are probably transitions to carcinoma. 

Adenomyomata op the Uterus and Tubal Corners Originating from 

THE Mucosa. 

These may be congenital and due to a fetal displacement of cells of 
the ducts of Miiller or to a post-fetal growth of mucosa. The latter 
origin is proven by the occurrence of lower and higher grades of hyper- 
plasia of the mucosa in the upper part of the corpus uteri and tubal 
gorners. It is beyond question that most of the uterine adenomyomata 
originate from the mucosa. Their frequent occurrence at the fundus 
and in the tubal corners is explained by the fact that this situation 
represents the highest point of union of the ducts of Miiller. The dis- 
appearance of the intervening wall and the formation of the fundus 
is an irregular and complicated process giving abundant opportunity for 
various degrees of cell displacement. The origin from the mucosa is now 
acknowledged even for numerous cases previously attributed to the 
Wolffian body. 

V. Recklinghausen considers the following characteristics to be proof 
of origin from the mucosa: (1) A situation in any portion of the 
uterus other than the dorsal wall and the tubal angles. (2) A develop- 
ment from the central or inner layers of the myometrium. (3) A close 
apposition of the tumor to the mucosa in the greater portion of its 
extent. (4) Numerous communications with the mucosa. (5) A 
tendency to surround the uterine cavity in its entire circumference. 
(6) The absence of special characteristics in the structure of the 
glandular portions of the adenomyoma. 

It may be said that a position on the ventral wall of the uterus 
speaks almost positivel}^ for an origin from the mucosa. A situation in 
the peripheral layers of the uterine wall does not necessarily speak 
against such an origin, for cells of the ducts of Miiller may be displaced 
peripherally. 

Doubtful Cases. 

It is claimed that the mucosa of the tubal angles is capable of forming 
glandular structures showing the characteristics believed to belojig only 
to those growths originating from the Wolffian body. 



SALPINGITIS NODOSA ISTHMICA. 201 

Salpingitis Nodosa Isthmica. 

Y. Franque described this condition. The thickenings are dne to 
groups of muscle tissue enclosing various epithelial structures. The 
groups are usually in the periphery, and in this case tubercles were 
found. The tubules are lined with cylindrical epithelium ciliated in 
parts, and cytogenic tissue is also present. Glands are found in all 
layers of the tube wall and, in the less affected areas, near the mucosa. 

Although the glandular structures possess the characteristics men- 
tioned by y. Recklinghausen, the mucosa of the tube is considered to be 
the source of origin hecause of the multiple connections ietiveen the 
glands of the udenotnyoma and the tubal mucosa. The peripheral 
situation of many of these structures is explained by a separation of 
the glands from the lumen of the tube through growth of the interyening 
muscle fibres. 

Gottschalk described an intraligamentous cyst in the mesosalpinx 
composed of multiple cysts, some as large as an orange. In the wall of 
the tube, and extending into these cysts, were found glands lined Avith 
simple cylindrical ciliated epithelium as in the, case of y. Franque. At 
numerous points were found direct comynnnications hetiveen these glands 
and the tube lumen, and for this reason the origin of the entire growth 
is referred to the tubal mucosa. No cytogenic tissue, however, was 
found. 

Opitz found under the serosa of the uterus several small rayomata. 
In the isthmus tubae of both sides were found several adenomyomata 
with the typical structures mentioned by v. Recklinghausen. Many 
direct communications betw^een the glands and the tube lumen were 
found, and the origin of these adenomyomata is therefore referred by 
him to the tubal mucosa. 

The communications between the adenomata and the mucosa of the 
uterus and tube may, however, be explained as follows: (1) The glands, 
probably derivatives of the AYolffian body, in their growth and extension 
may naturally open into the mucosa. (2) This is especially probable in 
the interstitial part of the tube, because normally its mucosa has no 
glands. (3) The cells of the Wolffian body which have been displaced 
become attached to the duct of ]\Iiiller (the future mucosa of the uterus 
and tube), and may thus lie near the inner surface of the uterus or tube 
after mesoderm has formed their muscular wall. (4) An abnormal 
union may take place between the ducts of ^liiller and the displaced 
cells of the tubules of the Wolffian body, and a continuation of this 
union constitutes, after development of the tubules and glands of the 
a.'lf'nomyoma, a communication between them and the uterine or tubal 
mucosa. 

The origin of adenomyomata in the tubal angles at least, is probably, 
in the majority of cases, the result of a displacement of Wolffian body 
cells, because they are found in the periphery, and because glands are 
absent in the interstitial portion. In addition, the glands often show the 



202 CYTOGENIC TISSUE. 

typical Wolffian body structure, and their epithelium is quite different 
from that of the tubal mucosa. As to the communications, these prob- 
ably result from the glands of the adenomyoma, especially if the epithe- 
lium of the communicating tubules differs from that of the tubal mu- 
cosa. The epithelial cells are of equal height, with nuclei arranged in an 
even line, while the epithelium of the tubal mucosa is often stratified 
and quite irregular. In addition, the communicating tubules often 
possess a muscularis. 

The present view is the following: (1) Adenomyomata of the 
uterus — the majority originate from the mucosa. Those situated dor- 
sally and peripherally, if the structure is absolutely characteristic, prob- 
ably originate from Wolffian body cells. (2 ) Adenomyomata of the 
tubal corners originate from the mucosa (the majority) or from the 
Wolffian body. (3) Adenomyomata of the tubal angles may originate 
from the mucosa, even though glandless, but the majority are to be re- 
ferred to the Wolffian body. 

Cytogenic Tissue. 

This tissue is usually present in those adenomyomata of the uterus 
and tubal angles whose origin has been referred to the Wolffian body. 
It is a reticular lymphadenoid tissue with a basis consisting of a delicate 
reticulum with closely grouped, small, flat, spindle and star-shaped, but 
especially round cells. It is found normally in organs possessing numer- 
ous glands and going through numerous epithelial changes, such as the 
uterus and the intestine. It is possible that the regeneration of the 
uterine epithelium and glands is performed by these cells, inasmuch as 
the large epithelial-like cells of the decidua result from these round cells. 

V. Recklinghausen believes that the cytogenic tissue results from a 
hyperplasia of connective tissue. Meyer believes it to be the result of 
an increase in the number of cells and vessels of the paroophoron, while 
others consider it to be developing muscle tissue. 

Pick considers the cytogenic tissue which forms the stroma of the 
uterus to be like lymphatic tissue found elsewhere in the body, and 
Leopold considers the uterus to be simply a large lymph gland. Pick 
says that this tissue is not normally present in the rests of the Wolff- 
ian body and the Wolffian duct, but only develops as the stroma of 
the tubules when the Wolffian body tubules develop in large amounts. 
Therefore, if there is only a slight development of the tubules, or if they 
are scattered as in the tubal angles, no cytogenic tissue is found, for its 
production goes hand in hand with the growth 'and activity of the glands. 

This question is of importance in determining the origin of glandular 
structures found in the myometrium. Pick, finding such glands in the 
dorsum of the uterus, attributed their origin to the uterine mucosa 
because, in spite of a slight growth of glands, much cytogenic tissue w?s 
present. 



CYTOGENIC TISSUE. 203 

On the other hand, according to Hartz, the presence of cytogenic 
tissue, whether there is great or slight development of glands, is an 
evidence of the presence of embryonal tissue which is either already 
differentiated or is still capable of further differentiation. He believes 
that cells are present in the epoophoron and paroophoron which have the 
power to proliferate and also to form cytogenic tissue. These round cells 
are then at a certain stage already differentiated embryonal cells lying 
in a fine meshwork of connective-tissue fibres. At another earlier stage 
they may be capable of further differentiation and are to produce epithe- 
lium, glands, and connective tissue. 

It is a fact that it is difficult to state w^hat tissues are to result from 
the various blastodermic layers in the early embryonal period. For 
instance, the cells of the mesoderm form connective tissue, muscle, 
bone, cartilage, etc., yet before the stage of differentiation the future 
of any group of cells cannot be determined by their form. For this same 
reason, displaced cells of the Wolffian body cannot be found or recog- 
nized in the uterine wall of the fetus and the newly-born, for they are 
then only embryonal cells which later on may form the characteristic 
structures of the Wolffian body. When, therefore, in the future devel- 
opment of such displaced cells of the Wolffian body, round cells and 
other cells of cytogenic tissue are found, these may be either embryonal 
cells destined to form new glands and cysts, or else they are already 
differentiated into permanent connective-tissue cells. 

As this cytogenic tissue is normally present in the uterus, its presence 
in pathological glandular growths cannot be viewed as proof either of 
an origin from the AVolffian body tubules or of an origin from the uter- 
ine mucosa. It must be stated, however, that in tumors of the epo- 
ophoron, and in adenomata of the ovary originating from epoophoron 
tubules, cytogenic tissue is present. In myomata of the corpus uteri 
islands of cytogenic tissue are also present without epithelial elements. 
Here either the latter have degenerated or else simply the stroma of the 
mucosa has been displaced without epithelial cells. This is of interest 
in explaining the desmoid tumors of the broad ligament, for in many of 
these glandular elements are not present. These mesodermal tumors 
may be then simply mesodermal cells displaced with or without the aid 
of the paroophoron. In the former event the epithelial elements may 
have disappeared. 



III. DUCT OF GARTNER AND GROWTHS ORIGINATING 

FROM IT. 

(a) Normal Anatomy. 

Robert Meyer found this duct in all fetuses of two to three months, 
in 28 per cent, of fetuses of four to six months, and in those of seven to 



204 GROWTHS FROM THE DUCT OF GARTNER. 

nine months in 16 per cent., frequently on both sides. In the newly-born 
it is found in 16 per cent. In children it was followed twice into the 
vagina. In adults, as in the fetus and in children, its remnants are 
found in the supravaginal part of the cervix. 

Its situation is originally in the lateral border of the uterus. In 
the cervix it takes a more mesial course, lying in the lower part of the 
supravaginal portion very close to the cervical mucosa. Further down, 
in the upper part of the vaginal portion of the cervix, it again lies more 
laterally. It is rarely found in adults in an uninterrupted course. It 
enters into the uterus at the lower part of the body both in children and 
in adults. In rare cases it may be traced from the fundus down. Its 
situation varies in that it may in different cases be more lateral or less 
external, or situated more or less anteriorly or posteriorly, usually more 
anteriorly. Although usually taking a straight course, it is sometimes 
twisted. 

In the fetus and in children it is a narrow cylindrical canal with 
branches, the canal becoming wider and more flattened in its own down- 
ward course. The dilated section in the cervix is called the "ampulla." 
Its walls present branches which pass into real glands. In adults it is 
present as remnants showing cystic degeneration, the main canal being 
rarely visible. The walls of the ampulla are smooth, but show projec- 
tions. From the ampullae extend wide branches or narrow tubules 
which run into straight or twisted glands. The glands are more numerous 
than in the fetus and in children, and occur in adenomatous bands, 
usually grouped about the main lumen, and may extend up to the mucosa 
and through the middle muscle layer. 

The epithelium of the duct of Gartner in the fetus and in children 
is simple cylindrical with a long nucleus. The cells stain well and 
show the same character in adults. The branches are lined with low 
epithelium. The narrow tubules have the lowest cubical epithelium. 
These stain poorly and are often overlooked. The epithelium, as men- 
tioned, is usually simple, though in pathological conditions it may be 
stratified. 

The duct of Gartner possesses a muscularis as a layer only in its 
upper part. This is sometimes, but rarely, arranged in three layers, 
circular and longitudinal. Generally a circular layer with a slight 
external longitudinal layer is present. This is sometimes quite sharply 
outlined from the myometrium, taking the stain better than the latter. 
In the vaginal portion of the cervix the muscularis is absent. 

The ampulla of the duct of Gartner in the fetus and in children is 
homologous with the pars ampullaris of the vas deferens. The gland- 
ular formations are hyperplastic. In adults they may cause adenomata 
and carcinomata. 

Koeberle found the duct of Gartner opening into the cervix at the 
level of the internal os of a one-horned uterus. Passable for a bristle, 
it was traced upward for a distance of 35 mm., whence it continued fur- 



GROWTHS FROM THE DUCT OF GARTNER, 205 

ther on to the parovariiim. It was lined with a mucosa of simple cubical 
epithelium. In a uterus bipartitus with vagina septa and atresia of 
right vagina, Koeberle found " the duct of Gartner opening into the 
right vagina. Klein traced the duct of Gartner in a newly-born infant 
from the right parovarium through the broad ligament, through the 
uterus and vagina, up to the hymen, with but one slight interruption. 
Baudelocque traced the duct of Gartner parallel to the uterine cavity 
from the intramural tube to the internal os, into which it opened. 

V. Recklinghausen finds that in adults remains of the duct of Gartner 
are generally preserved in the cervix as a fibrous or muscular cord. 
Sometimes a lumen lined with cylindrical epithelium is present. At 
times glands are found. In other uteri are found cytogenic tissue and 
glands, and in others simply islands of lumina lined with cylindrical 
epithelium. 

The part distal to the ampulla is homologous with the ejaculatory 
duct of the male. The ampulla develops at about the seventh month 
of fetal life. 

(b) Pathological Anatomy. 

((X) Cysts of the Duct of Gai-tiier in the Parametriiinio (See Vaginal Cysts.) 
(p) Cervical Cysts of Gartner's Ducts. 

These may be due to (1) post-fetal displacement of cervix mucosa, 
(2) to post-fetal displacement of cervix mucosa associated Avith cystic 
endocervicitis, (3) to mucosa implanted in cervical lacerations, (4) to 
a communication of cysts of the duct of Gartner with cysts of the mucosa, 
forming mixed cysts, (5) to products of the duct of Gartner or its 
branches. 

Small cysts are found in the fetus and in children. It is difficult to 
distinguish these from cysts of the cervical mucosa, especially as these 
cysts and those of the cervix may communicate, forming mixed cysts. 

(a) Small Cysts. 

Cysts of a diameter up to two millimetres are found in adults. They 
are of irregular shape and twisted, arranged in rosettes. Their epithelial 
cells are of varvino; heiofhts. 



■■& 



(h) Large Cysts. 

These displace the cervical tissue, especially in the lateral wall. In 
these the epithelium is so changed that it is difficult to tell whether the 
cysts originate from the duct of Gartner or from the mucosa. They are 
cysts of two to ten millimetres diameter, lined with low epithelium, 
rarely with cylindrical. The muscle fibres, especially about the larger 
cysts, are partly arranged in a circular manner. Those cysts not origin- 



206 GROWTHS FROM THE DUCT OF GARTNER. 

ating from the duct of Gartner are distinguished by the crossed course of 
the muscle fibres in their wall, thus differing from the tunica of the 
duct of Gartner. The contents of these cysts are composed of nuclei, 
leucocytes, mucus, and fibrin. 

(y) Adenomata and Adenocystomata of tlie Duct of Gartner. 

Such growths occur in the cervix and fornix. A decided location 
on the dorsum of the cer^dx or fornix of the vagina, however, speaks for 
an origin from the Wolffian body. 

Adenomata at the sides of the cervix or vagina are probably de- 
veloped from the duct of Gartner. With adenomyomata of the tu.be 
angles there has been found in one case a small cervical cystadenoma, in 
another case an adenocystoma of the duct of Gartner. 

(^) Adenomatous Hyperplasia of tlie Cervical Gland Appendage of 

the Duct of Gartner. 

This condition involves both the vaginal portion and the rest of the 
cervix, and is evidenced clinically by a soft, friable vaginal portio. The 
duct of Gartner is found lined with low, simple epithelium giving off 
long, dividing tubules, often twisting and turning, and lined with 
simple cubical and short cylindrical epithelium. These extend into the 
vaginal portion of the cervix and break into the muscularis. 

VAGINAL CYSTS. 
(a) Normal Anatomy. 

In the fornix and upper part of the vagina the duct is situated 
laterally and somewhat anteriorly. Further down it is situated more 
laterall}^ In its course through the vagina it lies quite near the mucosa. 
That the situation varies somewhat may be seen from the fact that MeyeB 
traced the duct of Gartner up to the hymen, finding it at first situated 
laterally, and then taking a more anterior course, and finally running 
more posteriorly into the middle of the lateral wall of the hymen up to 
its anterior layer. In the lower two-thirds it is generally lateral or 
antero-lateral. The duct of Gartner has been found to be lined even 
with two layers of epithelium in various portions of the vagina. A 
tunica of muscle fibres is rarely present. Cilia have not yet been found 
in the duct of Gartner in the human being, but Rieder believes that the 
epithelium may be ciliated. 

Meyer, after examining 60 fetuses and newly-born, comes to the fol- 
lowing conclusion concerning the glands of the vagina : 

Glands of the vagina are found : 1. Isolated in one-third of the cases. 
These are referred to a failure on the part of the projections formed in 
the first half of fetal life to develop into squamous epithelium. 



GROWTHS FROM THE DUCT OF GARTNER. 207 

2. Glands develop in the last montlis of fetal life from the basal 
stratum of the developed squamous epithelium. 

3. Epithelial heteroplasia from the cervix above, or vestibule below, 
occurs less frequently and appears as glandular islands or evidences 
itself through formation of mucous glands. Glands in the vaginal wall 
without connection with the mucosa belong to the vestibule or Wolffian 
duct or "Wolffian body. The opening of the Wolffian duct is generally in 
the hymen, in which it runs up to the free edge anteriorly. The squamous 
epithelium of the Wolffian duct before its opening belongs to the exter- 
nal layer of the hymen. This epithelium may be present on any side or 
may be quite absent. Glands of the W^olffian body have been found in 
one case in the upper part of the vagina. Anteriorly they were within 
the circular vaginal muscular layer : posteriorly external to it up to the 
pararectal connective tissue. They resemble the tubules of the Wolffian 
bodv. 

(b) Pathological Anatomy. 

The origin of vaginal cysts has been variously referred to the fol- 
lowing sources: 1. The duct of Gartner. 2. Cells or rests of the Wolff- 
ian body. 3. The glandular branches of the ducts of Gartner. 4. The 
real (?) glands of the vagina. 5, Double rudimentary vagina. 6. Union 
of vaginal folds. 7. Lymphectasise. 8. Edema and exudations or ser- 
ous traumatic exudations. 9. Accessory ureters. 10. Echinococci. 

Abel, Nagel, Gebhard, and Waldeyer have never found glands in the 
vagina. Yeith and Testut say that the vaginal glands of the lower 
portion of the vagina are displaced aberrant glands of the sebaceous 
glands of the vulva or of the glands of Bartholini. 

Cysts are found lined with cylindrical epithelium, with squamous 
epithelium, or with both, depending upon whether they develop from 
the body or from the ducts of the so-called vaginal glands. This is the 
view of those who believe that glands of the vagina may be present. 

Davidsohn found at the highest point of the right fornix, and de- 
scending along the posterior vaginal wall of the middle of the vagina, a 
series of irregular prominences like a cock's comb, each the size of a 
pea or smaller. The whole extended over an area of three to four centi- 
metres. In the submucous connective tissue were glands with cystic 
spaces lined ^Yith epithelium and often showing papillae. At many points 
there was a decided resemblance to the glands of the cervix, while in 
other areas the epithelium was cubical or flat. No cilia were found. 
These cystic spaces were situated in all layers of the submucosa, but did 
not extend into the muscle layer. A frequent connection between the 
glands and cysts and the surface or lining of the vagina was noted. 
The cylindrical epithelium in the ducts of communication showed trans- 
ition into the squamous epithelium of the vagina. Numerous transitions 
from glands to cvsts were noted. 



208 GROWTHS FROM THE DUCT OF GARTNER. 

For this reason and for the following reasons the origin of this con- 
dition was attributed to vaginal glands : 1. Because the cysts are multi- 
ple and of small size, 2. Because the epithelium is simple. 3. Because 
all previously described vaginal cysts said to originate from vaginal 
glands are also lined with simple epithelium. 

The origin of the glands of the vagina is attributed to a displace- 
ment of cervical epithelium into the vaginal area of the ducts of Miiller, 
or to a heteroplasia of the vaginal epithelium, practically constituting an 
erosion. This is believed for two reasons : 1. The cysts correspond to 
the ovula Xabothi, 2. The siands are exactlv like the glands of the 
cervix. This ^dew is upheld, although the cysts were arranged in a row 
like pearls and were situated in the lateral wall of the vagina. 

Others who have found vaginal cysts lined with both cylindrical and 
sciuamous epithelium attribute their origin to the duct of Gartner and 
explain the presence of squamous epithelium through the opening of the 
glands of the duct of Gartner into the vagina. As mil be seen later, 
squamous epithelium may result from the duct of Gartner. 

Chalot believes that cysts should be attributed to the duct of Gartner 
if the epithelium is cylindrical or ciliated, if they are situated in the 
antero-lateral portion of the fornix and upper vagina, and if the cyst 
is continued into the paracervical or cer^dco-ligamentous areas. If not 
so continued, and if lined with papilli^, he believes such cysts to originate 
from cells of the ducts of ^Miiller. 

V. Recklinghausen considers that the absence of cilia, and a situation 
in the lateral walls of the vagina, speak for an origin from the ducts of 
Gartner. Cilia argue for an origin from the Wolffian body cells, 

^^ann believes that cysts lined with cylindrical or ciliated epithe- 
lium, either single or arranged in pearl form, and extending into the 
upper part of the vagina or into the broad ligament, are due to the ducts 
of Gartner. 

{<^) Cysts in the Lateral TTaU. 

In a tabulation of fourteen cases, six were ascribed by their authors 
to the duct of Gartner, Veit attributed to the duct of Gartner a case 
of vaginal cysts arranged in pearl form which were combined mth a 
cystic tumor in the parametrium originating from the duct of Gartner, 
yet squamous epithelium was found in the cysts. 

Kleinwachter found an adenoma in the upper part of the vagina, at- 
tached by a broad base, and containing cysts like those originating from 
the parovarium. He attributes their origin to the "Wolffian body or to 
the Wolffian duct. 

(/^) Cysts in tKe Posterior Wall. 

In a tabulation of nine cases not one was referred to the duct of 
Gartner. ]\Iost were referred to vaginal glands, depressions of vaginal 
mucosa, or to a rudimentary vagina. They were usually lined with cylin- 
drical epithelium. Squamous epithelium was often present, and cilia 



GROWTHS FROM THE DUCT OF GARTNER. 209 

were also foimcl. If the orioin of these cvsts is not to be attributed to 
the Wolffian body, it is difficult to explain the position and tlie presence 
of cilia except on the theory of Knge. Xagel and Kossmann say that the 
vagina develops from the solid end of the ducts of ]\luller and is always 
squamous. Klein says it develops from the tubular distal end of the 
ducts of IMiiller and is at first lined with cylindrical epithelium. Ruge 
found ciliated epithelium in addition to squamous in hematocolpos. and 
holds the ^-icAv mentioned by Klein. 

(X) Cysts iu tlie Anterit r Vagiual "WaU. 

These are found to be lined ^vith cylindrical, squamous, or ciliated 
epithelium. In a tabulation of twenty-six cases, ten were attributed 
to the ducts of Gartner. Others were attributed to Littre's glands, 
vaginal glands, vaginal mucosa, and rudimentary A'agina. 

(_/} Cysts Scattered Over More than One Wall. 

Of six cases three were attributed to the duct of Gartner. Tliese three 
extended from below upward, being more anterior below, and passing 
then more posteriorly up to the fornix. Cylindrical epithelium was 
present in all: in one case squamous epithelium was found. 

Considerable light is thrown upon this question by Yassmer. He 
found a vasinal cvst in the lateral fornix of a 14-vear-old girl which 
certainly originated from the duct of Gartner. It began one-half centi- 
metre from the fundus uteri, consisting of three round lumina situated 
in the parametrium and surrounded by a connective-tissue mantle. On 
approaching the uterus they united into a common canal, entering the 
myometrium with the loss of the connective-tissue mantle, and passing 
internally and posteriorly into the cervix where it was situated near the 
lumen. In the vaginal portion it was found more external, ending near 
the fornix in the middle of the cervical wall. In the fornix the lumen 
was small, becoming gradually wider, and finally developing into a cyst 
with branching glands. 

On the vaginal wall Avere papillary prominences situated posteriorly 
and laterally. Into some of these prominences passed several glandular 
branches from the cyst. Further down in the vagina no traces of the 
duct were found, but papillary prominences were present on the lateral 
and anterior vaginal walls. 

From the parametrium into the cervix the lining of the ducts was 
simple epithelium. In the vagina this epithelium was also present, but 
it was not so high as in the cervix. The cyst was lined vith epithelium in 
one and two layers. Crypt-like branches Avere present. The cyst con- 
tained islands of stratified squamous epithelium. In certain portions 
a gradual transition from cylindrical to squamous epithelium Avas 
evident. 

In the parametrium the duct of Gartner possessed a tunica com- 
14 



210 GROWTHS FROM THE DUCT OF GARTNER. 

posed of a layer of circular and an external layer of longitudinal muscle 
fibres. In the myometrium it was surrounded by connective tissue only. 
In the cervix the connective- tissue covering was lost, and here the glandu- 
lar branches lay free in the muscle of the vaginal portion, as was also 
the case in the vagina, where the cysts possessed no muscle wall, but lay 
free in the connective tissue under the vaginal mucosa. A duct of 
Gartner was also found on the other side. It may be seen that squamous 
epithelium may be present in cysts of the duct of Gartner, and it is quite 
possible that the communications found between cysts and the vagina 
are simply the openings resulting from the growth of such cysts toward 
the vagina. Even though cilia have not been found in the duct of 
Gartner, it is quite possible that such may be present. In addition, 
cells of the Wolffian body may be the cause. It is also probable that the 
arrangement of cysts in a pearl-like row indicates an origin from the 
duct of Gartner, for such have been followed up into the paracervical 
tissue. 

The points which speak in favor of an origin from the duct of 
Gartner are : 1. A situation in the fornix and upper third of the vagina 
on the lateral or antero-lateral wall. The nearer to the vulva the cysts 
approach, the nearer are they situated to the mucosa and the more they 
approach the middle of the anterior wall. 2. An epithelial lining of 
cylindrical epithelium, or of both cylindrical and squamous. Cilia are 
possible. 3. The occurrence of papillae, which are rare. 4. An arrange- 
ment in pearl-like form. 5. Extension into the fornix and further up. 
The walls of these cysts are usually composed of the connective tissue 
belonging to the duct of Gartner, and sometimes contain muscle fibres. 
The presence of the latter, while not necessary for making a diagnosis, is 
jievertheless a point of importance. 



CYSTS OP THE LABIUM MINUS. 

(a) Normal Anatomy. 

'Glands of the Vulva in the Fetus and Newly -Born (Robert Meyer). 

The epithelium of the vestibule is of entodermal origin, and in the 
fetus up to five months is quite different from ectoderm. It extends often 
to the base of the nymphae, anteriorly on the area leading to the frenulum 
clitoridis, posteriorly to the frenulum pudendi, and even to the commis- 
sure of the labia majora. This vestibular epithelium is displaced in the 
later fetal months by ectoderm, and islands may be left behind of strat- 
ified cubical and transitional cells. This epithelium lines especially the 
glandular depressions in the sulcus vestibuli. 



GROWTHS FROM THE DUCT OF GARTNER. 211 

Glands of the Yestihulum. 

These are rarely entirely around the vaginal opening. The roof of 
the vestibule evidences mucous glands normally only in the preurethral 
area. They are absent behind the urethra. Mucous glands are some- 
times present in the paraurethral section of the sulcus vestibuli, usuallj^ 
only glandular depressions. Behind the duct of Bartholini is a rudimen- 
tary double extension of the same. Physiologically only one such acces- 
sory duct is present ; sometimes one or more additional have been found. 
Often glandular depressions with stratified cubical epithelium are 
found in the sulcus nympho-hymenalis. 

Glands in tlie Fossa Navicularis. 

These are : 1. Long gland tubules extending upward and retro- 
vaginal, in the muscle of the vagina or in the recto-vagina] septum. 
2. ]\Iucous cysts. 3. Islands of transitional epithelium. 

Glands of the Kymen. 

These are : 1. Vaginal glands on the inner vaginal surface. 2. Rests 
of the Wolffian duct. 3. Tubules from the fossa navicularis. 4. Genuine 
glands of the external vestibular layer. 5. Depressions of the latter. 
6. Cysts with squamous epithelium, also derived from the epithelium of 
the external layer (rare). 

Glands in the Nyniplice. 

These are : 1. Glandular depressions derived from the sulcus vesti- 
buli. 2. An heteropia of the vestibular epithelium. 3. Beginning seba- 
ceous glands ( ?). 4. Squamous epithelium cysts. 5. Sebaceous cysts in 
the sulcus interlabialis. 6. Mucous cysts in the inner surface anteriorly 
near the frenulum clitoridis. 

All mucous glands of the vulva and all the long extensions in the 
nymphas and posteriorly to the perineum are referred to the entodermal 
epithelium of the vestibule. The ento-ectodermal boundary disappears 
in late fetal life and the glandular depressions disappear. The mucous 
glands of the preurethral area and of the accessory duct of Bartholini, 
the mucous glands and solid extensions with transitional epithelium, may 
remain under the ectoderm. In the clitoris a pair of glands is often pres- 
ent. Their origin is not known (Robert Meyer). 

(b) Pathological Anatomy. 

The cysts are of three kinds : 

1. From the normal elements of the labia minora, and therefore 



212 MIXED TUMORS AXD DERMOID CTSTS. 

either sebaceous retention cysts or atheromata with contents of a seba- 
ceous character -^^dth concrements and cholesterin. Another form is 
lymph cysts. 

2. From structures pathologically present : (^a J displaced cells of cysts, 
(h) abnormally formed glands from the labial epithelium. The labium 
minus is ectoderm and no mucous glands can develop from this epithe- 
lium, nor are there any in it generally. Between the urethra and the in- 
troitus vaginae are the glandulte v^stibulares minores. Between the hymen 
and the small labia are the giandulte vestibulares majores (Bartholini). 
From displaced cells of these glands or from the glands themselves are 
formed cysts which may be of an acinous character, occasionally con- 
taining cilia, and also cystoid growths, (c) Retained entodermal cells. 

(3) Cysts from the Duct of Gartner. 

It ends at the sides of the introitus vagina or in the hymen in the 
external epithelial layer. An ending in the labia minora has not yet 
been found. Such cysts may be lined mth cylindrical epithelium and 
papilh-e. Another form is found in the upper third of the labium, 
including the vestibule, between the clitoris and urethra. These are lined 
with cylindrical epithelium, simple and stratified, also shoT^dng cilia 
and not infrequently squamous epithelium. The third form is gland- 
ular cystoma. 

^eber attributes the origin of such cysts to the duct of Gartner for 
the following reasons : 1. If the "Wolffian duct persisted it would remain 
in the upper part of the urogenital sinus and therefore in the upper 
third of the smaU labia. 2. These cysts are deeply situated, in contra- 
distinction to the superficial retention cysts. 3. The diagnosis is as- 
sured if there is a continuation along the vagina up to the fornix. 
4. The wall consists of connective tissue and often muscle fibres. 5. These 
cysts make a very early appearance and their growth is painless. 

lY. TOIORS RESULTING FROM CELLS DISPLACED BY THE 
AYOLFFIAX BODY AXD Y^OLFFIAX DUCT. 

(a) Noemae Ax^atomy. 

The primary vertebra are embryonal masses of mesoderm lying on 
each side of the chorda and medullary canal. In the human embryo their 
number, extending along the length of the body, is 35 to 37. They are 
bounded externally by ectoderm, mesially by the medullary canal, and 
ventrally by the aorta. Between the primary vertebras and the divided 
but unsegmented mesoderm there develops in the body segment the 
"intermediary band. 



J J 



MIXED TUMORS AND DERMOID CYSTS. 213 

Fig. 100 shows the dorsal portion of the body mesoderm changed or 
segmented into ' ' primary vertebrae. ' ' The ventral portion of the mesoderm 
is not segmented, but is divided so that the celom results. The mesial 
wall of each primary vertebra opens and the cells filling its centre, the 
nucleus, pass out of the primary vertebrae. These cells form the sclero- 
tom. The cells which have passed out envelop the medullary canal and 
the chorda and form the cartilaginous and subsequently the bony verte- 
brge. The form of each primary vertebra then gradually changes and 
becomes long and four-sided. It consists of a mesial plate (the muscle 
plate), a lateral plate (the cutis plate), and an upper and a lower angle. 
This is the myotom, from which originate the segmented striated 
muscles of the skeleton. The primary vertebrae furnish, through the 
myotom, striated muscle fibres and a portion of the mesenchym. 




Muotom ) Derivalives 

r of 

Sclerotorii i primary vertclyra 



^ ^il/i^-^ Wolffian duct 



U:^-'^^ 



-'*'( 



I (&: /^ 



ii-XvC^rf-^y^ Middle plate 



^C^ ■ -.%^^ >:vv6-**'-"' ^*f » '• V Ectoderm 
n ^i^^ fil^^-'/ Celom 
^^ gS^^^ >5^-/ Sornatopl 



intestine 



Figure 100. — SECTIO^- THRoroH a "Primary Segment" at the Posterior End of 
A Three-weeks-old Embryo. (Hertivig.J 

Mesenchym tissue is that part of the mesoderm which spreads every- 
where as the interstitial substance between the epithelial elements of the 
body, and forms smooth muscle fibre, mucous tissue, fibrous connective 
tissue, cartilage, bone, the lymphoid organs, blood vessels ( ?), blood ( ?), 
etc. 

The visceral layer of the divided mesoderm, which includes the 
celom, becomes the mesoderm of the intestinal canal. In addition to form- 
ing the connective tissue of the lungs, of the liver, and of the pancreas, it 
forms the submucosa of the intestine and the muscle fibres of the in- 
testinal wall. It furnishes also the mesodermal elements of the mesen- 
tery and the omentum. 

The parietal layer of the mesoderm becomes the mesoderm of the 
body wall and is connected externally with the ectoderm. It is invaded 
and filled out later by the ventral angle of the myotom gro^v^dng forward 
toward the anterior median body line. 



214 MIXED TUMORS AND DERMOID CYSTS. 

On the dorsal wall of the celom, where parietal and visceral mesoderm 
unite, lies a cell called the intermediary band and "middle plate." 
Here the Wolffian body develops. 

Most authorities say that the "middle plate" is a derivative of the 
primary vertebrse and forms the Wolffian body. We hold that the Wolff- 
ian body develops in the mesoderm at this point, but that it is, at least 
partially, a product of the ectoderm, as is also the Wolffian duct. We 
hold further that, though situated on the celom epithelium, the germinal 
epithelium is of ectodermal origin, resulting from cells carried down 
by the Wolffian body. At any rate, it is highly probable, on the au- 
thority of Spee, that ectodermal cells take part in the formation of the 
ovary. The peritoneum results from the celom epithelium and is of meso- 
dermal origin. 

In Fig. 100 is seen the "middle plate" at which later the Wolffian body 
develops. The Wolffian duct is also present close to the ectoderm. It 
is to be noted that they are not very close to the myotom, from which 
striated muscle develops, but lie in the mesodermal tissue, in the mesen- 
chym which furnishes smooth muscle fibres. 

The Wolffian duct lies next to the ectoderm, which furnishes epider- 
mis, hair, nails, the entire central nervous system, and the spinal ganglia. 
The Wolffian body and the Wolffian duct are able to carry with them 
in their changes of location ectodermal and mesodermal cells, which 
later produce those structures which they were destined to form had they 
remained in their normal situation. 

(b) Pathological Anatomy. 

(oc) Mixed Tumors of the Kidney 

To show the position of the Wolffian body it must be mentioned that 
an undescended testicle and the epididymis have been found united 
to the spleen in a premature fetus which showed numerous anomalies 
of development. The origin of this condition is to be referred to that 
period of embryonal development in which the anterior portion of the 
Wolffian body and the Wolffian duct (later the epididymis and the vas 
deferens) extend up to the region of the liver and are united to the 
diaphragm by the diaphragmatic band of the Wolffian body (page 178). 
Since the spleen develops in this region, a union between it and the cells 
of the subsequent testicle and epididymis must be taken for granted. 

The kidney finally develops in the position previously occupied by 
a portion of the Wolffian body. Mixed tumors of the kidney, described as 
rhabdomyoma, chondrosarcoma, angiosarcoma, myxosarcoma, and sar- 
coma, generally occur in early years, mostly in children under three years 
of age. A case in the fetus has also been described. They are situated 
mostly in the pelvis of the kidney or in the kidney substance, growing 
into the kidney as something foreign. They may be also situated out- 



MIXED TUMORS AND DERMOID CYSTS. 215 

side the kidney capsule, which speaks against their origin from the 
kidney tissue itself. The colon has also been found behind the tumor. 
In addition to glandular structures are found smooth and striated 
muscle fibres, cartilage, fat, elastic fibres, colloid and fibrous connective 
tissue. 

Birch-Hirschfeld and others believed that these tumors originate 
through the medium of the Wolf&an body. Wilms believes that they 
originate from mesodermal cells in the neighborhood of the Wolffian 
body which are displaced by the latter. He therefore calls them "meso- 
dermal tumors." 

According to Wilms, the tubular glands are not primary structures, 
but are outgrowths of certain cells of the embryonal tissue still in a stage 
of differentiation. From this embryonal tissue (the mesodermal cells in 
the region of the Wolffian body) originate all the above mentioned 
structures and also the glandular elements. The round cells of these 
tumors are not sarcoma cells ; they are embryonal cells which in their 
early stage have round-cell forms, and later, when differentiated, form 
epithelium, glands, etc. (see Cytogenic Tissue). These cells must orginate 
from a common area, because cartilage and striated muscle fibres are not 
found in the Wolffian body, and the displacement of cells forming these 
tumors from the substance of the Wolffian body alone, without participa- 
tion of mesodermal cells, would not explain the presence of these two 
tissues. 

(p) Ketroiieritoneal Dermoid Cysts. 

Dermoid cysts are found in the abdominal cavity, but are always re- 
troperitoneal. Muus described a mixed tumor of the kidney in which 
he found horny pearls. These were surrounded by epidermis-like cells. 
The presence of a stratum mucosum granulosum with keratohy aline nuclei 
and a stratum corneum proves them to be epidermis. This is a proof 
that in the displacement of cells cell groups, including both ectodermal 
and mesodermal cells, may be carried along. This is a proof that such 
a displacement of cells is not always of regular character, but is one 
which occurs with all possible variations, at one time more, at another 
time fewer, cells being removed from their original situation. 

Dermoid cysts in various situations of the abdomen have been de- 
scribed. Marchand mentioned a solid dermoid cyst- directly behind the 
kidney. Meckel reported one, containing twenty-one pieces of bone, 
teeth, and hair, situated near the diaphragm. Bonfigli mentioned a der- 
moid cyst, 13 cm. long and 4 cm. wide, situated in a strand extending from 
the liver and stomach. Zweifel described a retroperitoneal dermoid 
cyst extending from the diaphragm into the pelvis, pushing the kidney 
before it. Bardenheuer reported a retroperitoneal dermoid which had 
pushed the ascending colon posteriorly and externally and which was 
covered by the transverse colon. The pancreas was closely united to 



216 MIXED TUMORS AND DERMOID CYSTS. 

the tumor. Pommer describes a dermoid cyst situated in the omentum, 
and Mayer one attached to the mesentery of the colon on the right side. 
All these are to be brought into genetic relation with the ectodermal 
origin of the Wolffian duct. 

In Figs. 80 and 82 we seen the Wolffian body situated in the tissue 
which furnishes the mesodermal elements of the mesentery and the other 
abdominal organs. This tissue also forms the omentum, and it is only 
a question of the original position of the dislocated cells which determines 
in what portion of the mesentery such tumors may develop. 

ix) Mixed Tumors and. Dermoid Cysts of the Ovary. 

Dermoid cysts of the ovary frequently contain, in addition to epider- 
mis and hair, smooth muscle fibres, cartilage, bone, teeth, connective 
tissue, neuroglia cells, structures like spinal ganglia, and cysts. The 
latter may be lined with simple or stratified cylindrical epithelium or 
with ciliated epithelium. The inner surface may show papillary excres- 
cences, or may be lined with crypts containing beaker cells. In other 
words, we find in these dermoid cysts the same glandular structures £is 
are found in the various adenomata, cystomata, and cystadenomata of 
the ovary whose origin we have referred to the Wolffian body tubules. 

Our embryological discussion has furnished us with the following 
points, to which are added previously mentioned pathological statements : 

1. The pronephros furnishes, through its tubules, direct com- 
munication between the ectoderm and the celom. 

2. The Wolffian body furnishes, through its tubules, communica- 
tion between the celom and the Wolffian duct. 

3. The Wolffian duct develops near the ectoderm and in all 
probability from the ectoderm. 

4. The ovary develops from certain cells situated on the celom, 
the germinal epithelium. Cells from the Wolffian body mesoderm are 
concerned in the development of the ovary, and the tubules of the 
Wolffian body may themselves be employed in forming the ovary. 

5. Although the tubules of the parovarium usually are considered 
as ending blindly at the hilus, they actually extend into the vascular 
layer of the ovary, and 

6. The parovarian tubules may be found, as v. Franque has shown, 
in all parts of the ovary, even under the surface. 

7. The cystadenomata of the ovary develop from remnants or tubules 
of the Wolffian body. 

8. The various parovarian formations of the broad ligament show 
ciliated epithelium and are the remains of multiple segmental unions 
between the Wolffian body and celom and the Wolffian duct. 

9. The broad ligament represents the epithelial celom covering 
and the connective-tissue basis of the Wolffian body. 

10. The isolation of groups of cells from their normal relation and 
their removal from control is to be considered the cause of neoplasms. 



MIXED TUMORS AND DERMOID CYSTS. 217 

11. The cystadenomatous structures found in ovarian cysts are found 
also in dermoid cysts of the ovary. 

12. Pseudomucinous cystadenoma is often combined with dermoid 
cysts in the same or other ovary. 

13. The mixed tumors and dermoid cysts of the kidney and those 
situated retroperitoneally develop from mesodermal and ectodermal 
cells displaced by the Wolffian body. 

Therefore the pronephros, the Wolffian body, and the Wolffian duct, 
through their position in the mesoderm, their connection between ecto- 
derm and celom, their relation to the normal development of the ovary, 
their subsequent position at the hilus of the ovary, and the extension 
of the tubules into the vascular layer and their gro^i:h through the 
ovary even up to its surface, and from the fact that their remnants fur- 
nish the ciliated growths of the broad ligament and form the cystadenom- 
ata of the ovary, are capable of carrying ^^"ith them mesodermal and 
ectodermal cells up to or into the ovary, and of forming mesodermal 
and ectodermal products and structures lined with ciliated epithelium. 

Cysts of the testicle lined with ciliated epithelium originate from 
remnants of the Wolffian body tubules. Therefore the mesodermal 
tumors, the mixed tumors, and the dermoids of the ovary and testicle 
originate in this same manner. Cystadenomata of the testicle frequently 
include in their stroma cartilage centres or show other elements. 

Almost all the tumors of the testicle included under the names cys- 
toid, enchondroma, rhabdomyoma, cystosarcoma, and cystocarcinoma, 
together with mixed tumors of the testis, are found, on careful examin- 
ation, to contain ectodermal products. It is evident that just as the 
mesodermal mixed tumors show the various mesodermal tissues in vary- 
ing degrees, so may also the mixed tumors which are built of both 
ectoderm and mesoderm. If ectodermal cells are displaced to any 
extent, so that their presence is manifested by cutis-like tissue, hair, 
sebaceous glands, etc., we speak of dermoid cysts. If the displaced cells 
are, so to speak, located in one part of the organ concerned, and if they 
grow equally, and if the skin cells, as in the normal skin, and the sebaceous 
glands excrete their products, a cystic dermoid must result. Since the 
contents found in dermoid cysts are excretedby the so-called ''derm "of the 
cyst, they must lie, when secreted, between the derm and the enveloping 
tissue composing the organ or tissue in which the dermoids grow. The 
larger the amount of this secretion, the greater is the pressure exerted 
on the surrounding tissue. If the mass of secreted matter reaches a fair 
amount, and if it causes a tissue gro^^i:h in its periphery, and if it com- 
presses the enveloping organ or tissue so that it is stretched and flattened, 
we then have a cvstic dermoid whose wall consists of so-called "skin," 
of granulation tissue, and of the tissue of the enveloping organ. The 
original group of displaced cells is found then as a prominence only in 
one part of the so-called cyst wall, and it is this part which grows grad- 



218 MIXED TUMORS AND DERMOID CYSTS. 

ually for years, and in which are formed the hair, the sebaceous glands, 
and the other elements found on the inner surface of a dermoid cyst. 
The greater the amount of substance secreted, and the greater the amount 
and the number of products formed by the displaced ectodermal and 
mesodermal cells, the larger is the cyst. 

If, on the other hand, the displaced cells are not grouped in one part 
of the organ concerned, and if, at the same time, the ectoderm cells are 
not present in too great number, there develops a tumor in which the 
various tissue forms grow into each other. Since the ectoderm cells do 
not form in such a case a so-called ' ' derm, ' ' and since they cannot bring 
about the formation of a cyst through their excretion, as above described, 
a tumor form results which is relatively solid and which seems to be of an 
entirely different structure — a so-called "teratoma." 

We understand under teratomata only the tumors originating from 
displaced cells, and we may therefore divide the so-called "teratoid" 
growths into 

1. Mixed tumors. 

2. Dermoid cysts. 

3. Teratomata (solid dermoid cysts, usually of complicated struc- 
ture ) . 

It is, of course, to be understood that all these forms are only mixed 
tumors. The so-called "mixed tumors of the ovary" are of the follow- 
ing forms : enchondroma and osteoma, which are rare ; cystic sarcoma, 
myxofibroma, adenomyxocystoma. In comparison with the mixed tumors 
of the testicle they are rare. A comparison of the mixed tumors found 
in the ovary with those in the testicle shows that in the latter there is a 
prevalence of mesoderm products with a relatively infrequent presence 
of ectoderm elements. In the ovary, however, these tumors occur more 
frequently in the form of dermoid cysts than in the testicle. This may 
be explained by the fact that in the female the AA^olffian duct and the 
Wolffian body lie at the hilus as non-functionating organs, while in the 
male they form the vas deferens and functionating tubules. 

That enchondromata and osteomata occur frequently in the ovary 
seems to be overlooked, because these, almost without exception, occur in 
combination with ectoderm cells, i.e., as dermoid cysts and solid dermoids. 
This difference is explained, as above, by the fact that the Wolffian body 
and duct in the female remain as regressive structures and are more 
liable to growth on their own part and on the part of the cells which 
they have displaced. 'On the other hand, the Wolffian duct in the male 
forms the vas deferens, and a portion of the Wolffian body forms the 
head of the epididymis and the rete testis, while only a part undergoes 
regressive changes, and this part has not, like the Wolffian duct, been 
in close contact with ectoderm. 

In ovarian dermoids and teratomata ectoderm is present in large 
amount. Therefore teeth are frequently found, and their occurrence 



MIXED TUMORS AXD DERMOID CYSTS. 219 

is in contrast ^^dtli tlieir rarity in the testicle. The origin of teeth is to be 
explained by the nnited presence of ectoderm and mesoderm in these 
tumors. It is difficult to understand why, in the higher vertebrates, 
teeth normallv occur onlv in the mouth, for those tissue combinations 
which are necessary for the buildinp: of teeth, and which occur in the 
oral cavity, are also present in other parts of the body. KoUmann says : 
'^ The early cell formation and development of teeth is explained by 
comparative anatomy as a continuation of the tooth formation present 
upon the surface of the body of the lower vertebrates. The skin teeth, 
an evident organ of protection, are continued on into the oral cavity. 
Upon the jaws they reach, with their higher function, a higher stage of 
development. Their development in epithelium with the aid of meso- 
derm is a primary occurrence. Even in the lowest animal forms the 
teeth develop only through the participation of both these tissues. ' ' 

In dermoid cysts the teeth are embedded in bone, or in the wall of the 
cyst where no cartilage or bone is to be found; they may also lie in the 
cyst contents. Their number varies, even one hun^dred or more having 
been found in one cyst. The teeth lie, as a rule, on the inner surface of 
the cyst, and are rarely embedded completely within the wall — another 
fact which speaks for their origin, as explained above, for ectoderm or 
skin is found on the inner surface. A further interesting fact is that 
the teeth, in alb cases which we have examined, are always unilateral and, 
mth perhaps one exception among eleven cases which were examined for 
me by a skilled observer, correspond to that side of the body in which the 
cysts are found, i.e., in right-sided cysts were found right-sided teeth ; in 
life-sided cysts, teeth of the left side. The occurrence of teeth in der- 
moid cysts is not limited to the ovary alone, for they are found in der- 
moid tumors in the brain, the eve, the mediastinum, and in abdominal der- 
molds. The teeth may be either first or second teeth, and both forms may 
be found in the same tumor. They may be either molars, bicuspids, in- 
cisors, etc., and may represent the teeth of the upper or lower jaw. 

The dermoid cysts of the ovary do not always take their origin from 
the ovary. If, however, they do, the ovary may be entirely dilated by 
the tumor which has developed in it. On the other hand, the ovary may 
be found only in one part of the cyst wall in cases where the dermoid cyst 
originated at the hilus and grew into the broad ligament. Dermoid 
cysts may develop in the broad ligament, and the ovary takes no part 
in the formation of the tumor, but lies absolutely free, showing, however, 
as a rule various changes. 

Switalski found, in examining the ovary and appendages of a fetus, 
an ectodermal structure lying close to the Wolffian duct in the broad 
ligament near the hilus of the ovary. Cells of the stratum granulosum 
and stratum lucidum of the epidermis were present, as well as cells of 
the stratum corneum. Its close relation to the Wolffian duct makes the 
etiological connection between the dermoid structure and the Wolffian 
duct positive. 



220 MIXED TUMORS AND DERMOID CYSTS. 

The cells from which dermoid cysts develop may be carried into 
various parts of the ovary, so that several dermoids are present. 01s- 
hausen found in one case a proliferating cystoma of the ovary with two 
dermoid cysts of the size of an egg. In another case he found three 
dermoid cysts side by side. Wilms reported a case where five small der- 
moid cysts were present in one ovary. 

Among the other interesting structures found in dermoid cysts must 
be mentioned nails (finger nails), of Avhich very fine specimens are to 
be found in the museum of the Anatomical Institute in Vienna. 01s- 
hausen says : "It should not be considered strange if nails belonging 
to the skin are frequently found in dermoid cysts. The collection in 
the Gynecological Clinic in Halle contains a specimen of a dermoid cyst 
of a goose containing a large number of feathers." 

The dermoid cysts are frequently combined with proliferating cys- 
tomata. As a rule a cystoma is found in the same ovary in addition to 
a dermoid cyst, but more frequently there are found in the walls of the 
dermoid cysts smaller or larger formations of the same character as in 
simple proliferating cystomata. These two forms are to be distinguished 
from these combinations of two separate tumors, the one a dermoid, the 
other a cystoma, united through adhesion and perforation of the sepa- 
rating walls. The occurrence of a dermoid in one ovary with a cystoma 
in the other is by no means rare. Olshausen quotes a case of Flaischlen 
in which a proliferating cystoma, a dermoid cyst, and a sarcomatous 
degeneration of the connective tissue were present in the same ovary; 
the walls of the cyst showed sarcomatous degeneration. A case of Unver- 
richt showed, in the left ovary, the characteristic elements of a dermoid, 
and also red, spongy masses which were included as distinct nodules in 
the connective-tissue capsule. The case presented a round-celled sarcoma. 
Tumors of the same form were found in the cervix, peritoneum, omentum, 
liver, and diaphragm. Although the tumors in these latter situations 
are to be considered metastases, that in the cervix probably originated 
from the Wolffian duct in the same way as the main tumor in the ovary. 
That dermoids and teratomata should form metastases and undergo 
malignant degeneration into carcinomata, etc., is very natural, for they 
are nothing else than the cells of the patient, and may, therefore, pass 
through the same changes as the normally situated cells of the body. 

(/!} Mixed Tumors of tlie Vagina and Cervix Uteri. 

In Fig. 94 we see the ducts of Miiller and the Wolffian duct, the 
ureters (U) and the future bladder into which they empty. The point 
>S' (Fig. 90) becomes the hymen, and it may be seen that the Wolffian 
ducts {Wf. D.) would reach to the vaginal outlet. If the Wolffian duct 
carries with it mesodermal and ectodermal cells, it may be seen that they 
would lie (1) parallel to the future uterus, cervix, and vagina, or (2) 
between the uterus or cervix and the bladder, or ( 3 ) between the vagina 



MIXED TUMORS AND DERMOID CYSTS. 221 

and uterus on the one hand and intestine on the other, but always 
external to the peritoneum. ( See Fig. 90, where C represents the fold of 
Douglas, and where X represents the vesico-uterine fold.) 

Mixed tumors of the vagina (rhabdomyoma sarcomatodes, sarcoma 
fibrosum, myofibrosarcoma with striated muscle fibres, etc.) and mixed 
tumors of the cervix uteri (containing sarcomatous tissue with cartilage, 
striated muscle fibres, etc.) are attributed by Wilms to cell dislocation 
on the part of the AVolffian duct. This cell dislocation is not a displace- 
ment of finished cell elements, but is a removal of as yet undifferentiated 
mesoderm or mesenchym cells, which form only at their future seat of 
development tissues corresponding to the normal embryonal differentia- 
tion. 

Sarcoma of the vagina in children occurs during the early years 
and is characterized by its grape-like form. It almost always originates 
from the anterior vaginal wall. It is further characterized by a ten- 
dency to grow into the connective tissue between the bladder and the 
vagina. In many of these cases striated muscle fibres are present. 

In adults sarcoma of the vagina is either circumscribed or diffuse. 
It is never papillary as in children. It occurs as frequently on the pos- 
terior vaginal wall as on the anterior. In adults striated muscle fibres 
are infrequent. 

The same explanation as to origin is given for mixed tumors of the 
bladder wall and of the vas deferens. These mesodermal cells produce, 
later on, cartilage and myxomatous tissue, etc. 

According to Englisch, cysts of various forms, which are especially 
situated on the posterior wall of the bladder, and more especially between 
the bladder and rectum of the male, originate from remains of embryo- 
nal structures, from the Wolffian body and the ducts of Miiller, or 
through cystic dilatation of the seminal vesicles and prostatic sinus. 



(£) Dermoid Cysts of the Cervix. 

These are not common. Geyl described one containing among other 
tissues bone, muscle fibres, nerve, etc. Kiister and Nelaton have de- 
scribed dermoid cysts between the bladder and the uterus, but properi- 
toneal. 

(C) Dermoid Cysts of the Pelvic Connective Tissue. 

Dermoid cysts in the region of the bladder are rare. Martini report- 
ed a case where the posterior wall of the bladder had the character of 
the external skin and was furnished with hair and hair follicles (trichi- 
asis vesicae). 

Many cases classified as dermoids of the pelvic connective tissue are 
vaginal dermoids, because they have originated in the paravaginal cell 
tissue. These may, considering the course of the duct of Gartner, be 



222 MIXED TUMORS AND DERMOID CYSTS. 

reckoned with dermoid cysts of the paravaginal tissue, jnst as vaginal 
cysts originate from remains of the duct of Gartner, 

Dermoid cysts of the pelvic connective tissue are situated in the 
subperitoneal connective tissue between the rectum and the coccyx or 
between the rectum and the sacrum, or in the connective' tissue beneath 
the fold of Douglas and above the recto-vaginal septum. They are sit- 
uated above the pelvic diaphragm. They occur more frequently on the 
left side. Some of these may originate through participation of the 
caudal intestine, and for that reason the epithelial cells which have been 
carried up (see page 173) may be situated more to the left, because of the 
situation of the rectum on the left side. Another portion of these are 
probably due to the Wolffian duct. 

These dermoid cysts are distinguished from those of the ovary in 
several ways : 1. Situation, extent, structure, and growth are quite 
different from the intraligamentous subperitoneal cysts of the ovary, 
by which are meant also the proliferating cysts of the ovary and par- 
ovarium. 2. The situation within the pelvic connective tissue; the 
thin wall of these dermoids, which consists usually of one chamber; the 
characteristic displacement of the rectum, the vagina, the uterus, and 
the levator ani, and their growth downward toward the perineum, are 
typical. 3. A connection between dermoids of the pelvic connective 
tissue and the ovary has never been observed clinically or anatomically. 
4. These dermoid cysts have a smooth, thin wall, containing little 
hair and rarely bone. 

(V) Dermoid Cysts of the Uterus. 

Dermoid cysts probably situated on the inner surface of the uterus 
have been described by Kiwisch, Wagner, Cousot, Bartlett, Stewart, and 
others. They have usually been described as pedunculated. As the 
majority of these have appeared duTing labor, after extraction by forceps, 
they have generally been classified as dermoids of the pelvic connective 
tissue which have been expressed through tears of the cervix, the vagina, 
or the perineum. It must be mentioned, however, that some of the 
descriptions ascribing their origin to the uterus are very positive. 

We see that the Wolffian body and the Wolffian duct are in a position 
to take with them cell complexes into a fairly large area, as is observed 
in: 

1. Mixed tumors of the kidney, in which are found smooth muscle 
fibres, striated muscle fibres, cartilage, fat, mucous tissue, etc. 

2. Dermoid cysts of the kidney and retroperitoneal and mesen- 
teric dermoids. 

3. Mixed tumors of the cervix, vagina, bladder, and vas deferens, 
in which, among other elements, are found striated muscle and cartilage. 
As may be seen in Fig. 100, the Wolffian duct lies nearer than the Wolffian 
body to the myotom, from which come striated muscle fibres. The 



MIXED TUMORS AND DERMOID CYSTS. 223 

further the Wolffian duct goes in its course to the cloaca, the further does 
its lower end become separated from the ectoderm; and since the lower 
end of the duct alone and not the Wolffian body is the origin of the 
mixed tumors and the dermoid cysts of the cervix and vagina, these occur 
in the latter situation less frequently than in the ovary. For this reason 
also the dermoids of the ovary rarely contain striated muscle fibres, 
because the Wolffian body and the upper portion of the Wolffian duct are 
not so near the niyotom. 

4. Dermoid cysts of the cervix and the vagina, and those between 
the bladder and the uterus and in the pelvic connective tissue. 

5. Mixed tumors of the testicle, described under the names 
' ' adenocystoma, chondroadenoma, chondrosarcoma, adenomyosarcoma, 
etc.," in which are found cysts with cuboidal cylindrical epithelium, 
with or without cilia, as well as stratified ciliated epithelium, mucous 
tissue, cartilage, and sometimes muscle tissue, fat, and less frequently 
bone. 

6. Dermoid cysts of the ovary and testicle. 

That the mixed tumors of the cervix and vagina should have a less 
complex structure than the mixed tumors of the kidney is easily under- 
stood when w^e consider that the former are caused by displacement of 
cells by the Wolffian duct alone, for this does not come in contact with 
so many varying tissue cells of the mesoderm as does the Wolffian body, 
and when we consider, further, that its lower end. which finally reaches 
the future cervix and vagina, does not come in contact with the Wolffian 
body. For, these reasons we rarely find in these latter mixed tumors of 
the cervix and vagina the numerous cystic formations which are present 
in growths resulting through tlie medium of the Wolffian body. 



INDEX. 



Abdominal cavity, 165 

pregnancy, 117 
Abel, K., 207 
Abortion, 84 

criminal, 97, 106 
Abscesses in the tube wall, 132 
Accessory tubes, 115, 174, 186 

ostia, 174 
Acidum aceticum, 8 

chromicum, 8 

osmicum, 8 

carbolic, 10 
Actinomycosis of the tubes, 137 
Adenocarcinoma of the cervix, 66 

ovarii cysticum, 157 

endometrii, 102 

sarcomatodes cervicis, 67 
Adenocystoma of the duct of Gartner, 

206 
Adenoma, beginning malignant, 104 

destruens cervicis, 66 

endometrii, 102 

polyposum cervicis, 54 
Adenoma of the epoophoron, 187, 191 

mesonephritic, 187 

of the cervix, 193 

of the ovary, 188 

of the uterus, 199, 200 

of the tube angles, 195, 199, 200 

of the post. abd. wall, 193, 198 

of the duct of Gartner, 206 
Adenomatous hyperplasia of the gland- 
ular appendage of duct of G, 206 
Adenomyoma of the uterus, 195, 201 

of the tube angles, 195, 201 
Adenomyosarcoma of the uterus, 110, 

161 
Adenomyxocystoma of the ovary, 218 
Adenomyxosarcoma of the cervix, 67 
Adenosarcoma of the cervix, 67 

cystic, of the cervix, 67 
Adherent villi, 88 

in tubal gestation, 119 
15 



Adhesions, peritoneal, 134 

Aether, 7 

Albuginea ovarii, 141, 146 

thickened, 146 
Albuminates, 7 
Alcohol, absolute, 5, 8 

with HCl, 14 

70 per cent., 18 

action on connective tissue and 
epithelium, 73 
Allantois duct, 165, 166, 167, 171, 173, 

179 
Alum carmin (with formalin), 8 

of Grenach, 7 
Alumen pulveratum, 14 
Amann, 186, 208 
Amniotse, 167 
Amphibias, 167 
Ampulla (Wolffian tubules), 191, 195, 

197 
Ampulla tubas. 111 
Amyloid liver, 9 
Anal opening, 164 

membrane, 175 

groove, 175, 176 

prominence, 175, 176 
Anilin-oil xylol, 16 
Anilin water, 17 
Anus, 164, 167, 172, 173, 175, 176 
Aorta, 167, 169 
Appendicitis, 137 
Arbor vitse uterinus, 32 
Arteria hypogastrica, 140 

umbilicalis, 140 

uterina, 140 
Aschoff, 183 
Ascites, bloody, 158 

B 

Bacterium coli, 125, 128 
Bardenheuer, 215 
Bartholini's glands, 22, 179, 211 
Beigel, 182 
Benda, 10, 60 



226 



INDEX. 



Bergamot oil, 14 
Billroth-Liicke, 55 
Birch-Hirschfeld, 215 
Bismarck brown, 25 
Bladder, 138, 171, 173, 174, 176 
Blastoma, 168 
Blastodermic layer, 165 
Bleeding in the tube, in heart affec- 
tions, 123 

in tuberculosis of the endome- 
trium, 118 

in glands, 96 

with polyps, 99 
Blood cells, red, 8, 14 
Bonfigli, 215 

Bowman's capsule, 169, 184, 198 
Breisky, 55 

Broad ligament, 59, 132, 139, 183, 185, 
192 



Canada balsam, 13 
Canalis neurentericus, 164 
Cancroid, 101 

of the vaginal portion, 57 
Carbol-fuchsin, 17 
Carbol-xylol, 8 
Carcinoma (definition), 60 
Carcinoma of the vulva, 25 

of the vagina, 27 

beginning, 43, 46 

of the cervix, 57 

of the endometrium, 100 

of the tube, 139 

of the ovary, 157 

of the rectum, 172 

syncytiale, 108 
Carcinoma alveolus in a vein, 58 
Carcinoma "nests," 60 

alveoli, 60 

composition, 60, 61 

"cones," 102 

cells, 61 
Carcinomatous ulcer, 59 
Carmin powder, 13 
Caudal tubercle, 165 

intestine, 172, 173 
Cauliflower growth, 66 
Cauterization, 45 
Cecum, 139 
Celloidin. 11 

Celom, 165. 167, 168, 170, 173, 176 
Celom epithelium, 165, 166, 174, 180, 
192, 197, 214 



Cement substance, 7 
Cervical glands, 32 

canal, 4, 32 

polyp with carcinomatous squam- 
ous epithelium, 56 

polyps, 52 
Cervix catarrh, 48 

mucosa, swelling, 42 
Cervix uteri — adenocarcinoma sar- 
comatodes, 67 

adenoma, 193, 206 

adenoma destruens, 66 

adenocystoma, 206 

adenomyxosarcoma, 67 

adenosarcoma, 67 

carcinoma, 57 

cysts, 205, 206, 212 

cystadenofibroma, 68 

dermoid tumors, 221 

duct of Gartner in, 204 

endothelioma lymphaticum, 67 

external os, 28, 45 

internal os, 28, 69 

fibroma, 68, 193 

fibromyoma, 68 

hypertrophy, 49 

inflammation, 39, 42 

leiomyosarcoma, 68 

malignant adenoma, 66 

mixed tumors, 221 

myoma, 68 

myosarcoma, 68 

neoplasms, 49 

normal, 28, 29 

pathological, 37 

polyps, 52 

rhabdomyosarcoma, 68 

sarcoma, 66 
. sarcomatous degeneration of my- 
omata, 68 

tears, 42 

tuberculosis, 68 
Cervix wall (post) hypertrophy, 68 
Chloride of zinc cauterization, 45 
Chloroform, 7 
Chorda, 172 
Choriocarcinoma, 108 
Chorioma, syncytiale, 106, 107 

endotheliale, 107 

growth, 106 
Chorion, 105 
Chorionic villi, 82, 87, 88, 128 

in placental polyps, 97, 106, 107 

in metastases, 106 



INDEX 



227 



Chorionic villi in extrauterine preg- 
nancy, 120 
Chromic acid, 8 
Cilia, 46, 154, 160, 167, 169, 182, 184, 

185, 186, 190, 192 
Climacterium, 145 
Clitoris, 176 
Cloaca, 164, 166, 167, 170, 171, 179 

entodermal, 171, 172, 173, 174, 175 

ectodermal, 175 
Cloacal groove, 179 

plate, 175 

membrane, 165, 167, 171, 173, 175 
Cohnheim, 93, 94 
Colloid carcinoma, 101 
Colpitis emphysematosa, 27 

granulosa, 27 
Colpohyperplasia cystica, 27 
Collum uteri, 28 
Columnse rugarum, 26 
Compact layer, 79 
Condylomata acuminata, 

vulvae, 24 

vaginae, 27 

of the portio vaginalis, 50 
Cooper, 3 

Corpus albicans, 144 
Corpus luteum, 134, 136, 143, 144, 145, 
146 

abscess, 136, 147 

cysts, 150 

spurium, 143 

verum, 143, 145 

serosae, 141 
Cumulus proligerus, 142 
Curette, 4 

in cervix carcinoma, 60 

in extrauterine pregnancy, 89 
Cylindrical epithelium in place of 
squamous epith. on the portio, 45 
Cylindrical epith. of the endometrium 

in pregnancy, 80 
Cylindrical epith. in erosion glands of 

the portio, 46 
Cylindrical celled carcinoma, 157, 158 
Cystadenoma of the cervix, 68 

carcinomatous degeneration, 157, 
158 

ovarii carcinomatodes, 157 
of the post, abdominal wall, 193 
of the ovary, 153, 154, 155, 158 
Cystadenoma of the uterus, 162 
Cysts of the cervical mucosa, 43 
in endometritis fungosa, 95 



Cysts, cervical, of duct of Gartner, 205 
dermoid, 215, 216, 217, 218, 219, 

220. 221 
grape-like of the ovary, 189 
in sarcoma, 104, 218 
of the hymen, 26, 211 
of the vagina, 28, 206, 207, 208, 

209, 210 
of the vulva, 26, 210, 211 
of the vestibule, 210 
of the fossa navicularis, 211 
ovarian, 188 

of the myometrium, 193 
of the nymphae, 2il 
of the labium minus, 210 
parovarian, 186 

Cystocarcinoma of the testicle, 217 

Cystofibroma of the lig. teres, 191 

Cystoid of the testicle, 217 

Cystomata 

glandular or papillary pseudomu- 
cinous of the ovary, 188, 217 
mesonephritic, 186 
of the epididymis, 190 | 

of the ovary, 186 
of the broad ligament, 192 
retrouterine, subperitoneal, 194 
simple serous of the ovary, 188 
serous papillary of the ovary, 188, 
189 

Cystomyoma of the broad ligament, 192 

Cystosarcoma of the testicle, 217 

D 

Davidsohn, 207 
Decidua basalis, 82 

extrauterine pregnancy, 82 ; 

grooving, 84 

menstrualis, 76 ? 

spontaneous expulsion, 8S ^ 

tubaria basalis. 118 

tubaria capsularis. 120 

tubaria vera, 119 
Decidua cells, 81, 85 

of the tubal mucosa, 117 
Deciduoma, 105 

malignum, 108 
Deciduo-sarcoma uteri giganto-cel- 

lulare, 108 
Decubitus ulcer (vagina), 27 

of the portio (prolapse), 41 
Degeneration, beginning carcinoma- 
tous, 57 

colloid, in ovarian cysts, 156 



22S 



DsDEX. 



Degeneration, malignant, in cervix 
polyps, 56 

myxomatous. 5-i 

in dermoid cysts, 159 

in sarcoma, 67 

pseudomucinous in ovarian cysts. 
156 

sarcomatous in cervix myomata or 
fibromata, 67 

of the endometrium, 104 
Degenerations. 7 
Dermoid cysts 

of the kidney, 215 

retroperitoneal, 215 

of the ovary, 159, 216 

of the cervix. 221 

of the pelvic connective tissue, 221 

of the bladder, 221, 222 

of the uterus, 222, 223 
TDesmoid tumors. 192 
Destructive neoplasms of the endome- 
trium, 92 
Diagnosis, 22 

Diaphragmatic band, 178. 214 
JDifferential diagnosis between decidua 
menstrualis. abortion, and ex- 
trauterine pregnancy, 85 
"Differentiation. 14 

Digital examination of ut. cavity, 108 
Dilatation (of the uterus), 4 

with iodoform gauze, 4 

rapid, 4 
Discus proligerus. 142 
Displacement of cells. 189. 191, 203, 

212. etc. 
Diverticula. 167 

of the tube canal, 116 
Doderlein, 194 
Dohrn. 182 
Doubtful cases. 200 
Douglas, 194 
Dysmenorrhea membranacea. 75 

Echinococcus, 1, 207 

of the ovary, 148 
Ectoderm. 165, 170, 175, 176, 180 
Ectodermal intestine, 176 
Ectropion (cervix), 42, 45 

congenital, histological, 48 
Edematous infiltration of connective 

tissue in sarcoma, 67 
Eiermann, 106 
Elastic fibres, 7, 127 

staining. 15 



Elastic fibres of the cervix, 31 

in the ovary, 141 
Elephantiasis (vulvse), 25 
Elongatio colli, 49, 52, 57 
Embedding of specimens, in celloidin, 
10 

in glycerin-gelatin, 9 

by freezing. 10 

in paraffin, 11 
Embryonal connective tissue, 88, 107 

origin, 94 

fibrillary, 14 
Emphysema vaginae, 27 
Enchondroma of the testicle, 217 

of the ovary, 218 
End intestine. 164 
Endometritis. 92 

atrophicans. 94 

decidual, 99 

exfoliativa. 75 

fungosa. 94 

gonorrhoica. 92 

hypertrophica, 94 

interstitialis, 92 
Endometritis decidualis, scirrhous 
form, 97 

polyposa, 97 

tuberosa, 97 
Endometrium. 70 

carcinoma. 100 

inflammation, 92 

extrauterine pregnancy, 82 

division of vessels. 73 

differential diagnosis, 85 

hyperplasia, 92, 97 

lymph vessels. 74 

malignant adenoma, 102 

neoplasms, 100 

during menstruation. 74 

in the first months of intrauterine 
pregnancy, 78 

in myoma uteri. 109 

sarcoma, 104 

tuberculosis, 108 
Endometrium, neoplasms, 100 

normal anatomy, 70 

pathological anatomy, 89 

submucosa. none, 70 
Endothelioma Ijrmphaticum of the cer- 
vix, 67 
Endothelioma ovarii. 159 
Endothelium of the chorionic villi, 87 
Entoderm. 166, 175 
Entodermal space, 166, 179 
Eosin. 11. 15 



Ds'DEX. 



229 



Epididymis, 1S5, 1.90 
Epithelial inclusions,, 1^*0 
Epithelial formations i in myomata), 
109 
in adenoma of the epoophoron, 1ST 
in adenoma i mesonephrlticj of the 

ovary, 187 
in ovarian cysts, 188, 189 
in fibroadenoma of the lig. teres, 

191 
in paroophoral cysts of the broad 

ligament, 192 
in cystomyomata of the broad 

ligament. 192 
in adenomata and fibromata of the 

cervix, 68, 192 
in adenomata and cystadenomata 
of the post, abdominal -^all, 193 
in the myometrium, 193 
in retrouterine cystomata, 19-i 
in adenomata of the tubal angles, 

195 
in adenomyomata of the uterus 

and tubal angles, 195 
in adenomata of the uterus and 

tubal corners, 199 
in adenomyomata of the uterus 

and tubal corners, 200 
in doubtful cases, 201 
in the parametrium, 205 
in the cervix, 205, 206 
in the vagina. 206, 210 
in the labium minus, 210 
in the vulva. 210, 211 
in mixed tumors, 214, 222 
in dermoid cysts, 214, 222 
Epithelial nests, no carcinoma, 60 
Epithelial prominence, 113, 175 
Epithelial growths and carcinoma. 43 
atypical. 50. 69, 137 
in glands. 13. 43 
Epithelioma. .51. 150 
ectodermale. 108 
ectodermo-syncytiale. 108 
syncytiale-ectodermale, 108 
Epithelium of the follicle, 180 
Epoophoron. 182. 183. 188 

growths of epoophoron. 1S5. 189 
Erosio epithelialis superficialis, 45, 47 
follicularis. 47 
isolated, 48 
origin. 47. 4S 
papillaris 47. 
simplex. 47 



Erosions, 43 
External migration, 110 
Extirpation, partial, in portio carcin- 
oma. 5S 
Extractum hyirasri:^, 43 



Extrauterii.^ 






58 



F 

Far, proportion of, 7 

Fibri-, 14 

Fibroadenoma of the epoophoron, 1S7 

of the lig. teres, 191 
Florooy.^-- :: -.he utems, 109 
Fioroma o: the cervix, 68, 193 

of the vagina, 28 

of the vulva, 26 
Fibromyoma of the cervix, 68 

of the vagina, 28 

of the utems, 109 

lymphangiectaticum, 100 

cavemosum, 109 
Fibrosarcoma :: :h- 'r-J.-rz.^. io 
Fimbria ovarica, 11- IS: 

attachment of "jvim cm. 117 
Fimbria. 127 

of the tube, 114 
Fimbrian ends, union of. 137 
Fischel, 48 
Fixing fluid. 5 
Flemming's solutlor. S 
Flexura sigmol :" - 1. : 11 . 139 
Follicles, vesicular form of. 142 

bursting of, 143 

bleeding in. 144 

epithelinm. 14 S. 151. ISO, IS 9 

Graafian, 142. 143, 180 

primary. ISl 

ripening of. 142 

serous exudation in, 14S 
Folliculus vesiculosus, 142 
Formaldehyde. 19 
Formalin ('4 per cent.), 10 

I' 40 per cent.) , 19 
Fornix, 1S2. 193. 210 
Fossa hypogastrica. 140 

obturatoria. 141' 

ovarica. 140 

ovarii. 140 

paravesical! s ant., 140 

paravesicalis post, 140 
Fraenkel. E-;^^-. 12S 
Fraenkel. L., 106 
Fraenkel. A.. 12S 
V. Franque. ISS, 206 



230 



INDEX. 



Freund, W. A., 115, 163 
Friedlander, Carl, 7, 50, 69, 137 
Fritsch, 4 

Frozen sections, 6, 8, 11 
Fuchsin-resorcin stain, 15 
Fundus uteri, 69 
Fungus, 94 

Furrow, grooving of endometrium in 
extraut. pregnancy, 84 

G 

Gabbet, 17 

Gartner's Duct, 28, 164, 181, 182, 185, 
191, 194, 203, 208 

growths from the, 203, 213 

mixed tumors and dermoid cysts 
from, 220, 221, 222 

situation, 101, 182 
Gebhard, 207 
Gelatin layer, 9 
Generative organs, 166 
Genital prominence, 175 
Genital or sexual strand, 177 
Gentian violet, 17 
Germinal vesicle, 142 
Germinal spot, 142 
Germinal epithelium, 141, 150, 180, 

181, 189 
Giant cells, 68, 69, 104, 106, 148 

in dermoids, 159 
Giraldes, organ of, 184, 185, 186, 189, 

190, 197, 198 
Glands — atrophy, 94 

carcinoma, 57 

epithelium, changes during preg- 
nancy, 79 

in cervix polyps, 53 

in decidua of extraut. pregnancy, 
83 

in sarcoma, 104 

increase of, 57 

limits, 66 

polyp, of the endometrium, 100 
Glands in myoma, 162, 163, 193 

subserous of uterus, 193 

in salpingitis nodosa isthmica, 201 

of vagina, 207, 208 

of vulva, 210 

of vestibule, 210, 211 

of fossa navicularis, 210, 211 

of hymen, 210, 211 

of nymphse, 211 

in mixed tumors and dermoid 
cysts, 214, 224 



Glands in various growths of the geni- 
talia (see Adenoma) 

Gland enlargement, in the endomet- 
rium of pregnancy, 79 

Gland type, preservation of, in hyper- 
plasia, 102 

Gland wall, invagination of, 73 

Gland appendage, cervical, of duct of 
Gartner, 206 

Gland formations in cervix myoma, 
68 

Glass cylinder, 9 

Glass rod, 6 

Glomeruli, 167, 169, 170, 173, 190, 193 

Glycerin, 6, 7, 9, 10 
gelatin, 9 

Gonococci, 16 

Gonorrhea, 23, 27, 34, 50, 92, 128, 147 

Gottschalk, 106, 201 

Graafian follicle, 142, 148, 150 

Gram's method, 17, 25 

Granulation tissue, 108 

Grape-like cysts, 189 

Graviditas tubaria infundibularis, 117 
interstitialis, 117 
propria (ampullaris), 117 
tubo-abdominalis, 117 
tubo-uterina, 117 

Grenach, 7 

Gtinther, 17 

Gusserow, 55 

Gubernaculum Hunteri, 178, 181, 191 

Gynatresia, 122 

H 

Harpooning (of abd. tumors), 1 

Hartz, 193, 203 

Head kidney, 164, 167 

Hematoma ovarii, 146 

Hematosalpinx, 122 

Hematoxylin, 11, 14, 15, 101 

Hernial dilatations of the tubal canal, 

116 
Heteroplasia, 206 
Hilus ovarii, 140, 161 
Horn substance, 7 
Hyaline masses, 14 
Hydatids, pedunculated, 116, 184, 185 
Hydrosalpinx, incision, 127 

intermittent, 127 

puncture, 127 
Hydrocele (Nuck), 191 
Hydroparasalpinx, 184 
Hymen, 23, 174, 179, 182, 185 



INDEX. 



231 



Hymen, glands of, 211 

duct of Gartner in, 207, 212 
Hyperplasia, of the whole endomet- 
rium, 97 
circumscribed, 97 
diffuse, 97 
polypous, 97 
Hyperplasia of the glands of the endo- 
metrium, 99 
circumscribed, 100 
diffuse, 99 
polypous, 100 
Hyperplasia of the cervical glands, 

42, 43 
Hyperplastic formations in the cir- 
cumference of the carcinoma, 
90, 91 
Hypertrophy (glandular) of the cer- 
vix, 43 
of the cervical lips, 49 

I 

Infection, gonorrhoic, 97, 147 

septic, 97, 147 
Infectious diseases, 123, 146 
Infiltration (small celled) in car- 
cinoma, 61 
Infundibulum tub«, 110 
Inguinal ring, 178, 188, 191 
Inguinal band, 191, 192 
Instrumentarium, 20 
Intestinal canal, 165, 166 
Intestine, 171, 17z, 173, 175 
Intestine (end), 164 
Intestine (caudal), 172, 173 
Intestine, ectodermal, 176 
Intervillous blood spaces, 107 
Invagination of a gland wall, 73 
Iodoform gauze, 4 
lodoform-introducer, 4 
Israel, 6 
Isthmus tubae, 110 

K 

Kehrer, 188 

Keibel, 173 

Kidney (head), 164, 167 

Kidney, 164, 179, 214 

mixed tumors of, 214 

dermoid cysts of, 214 
Kidney pelvis, 180 

calyces, 180 

tubules, 180 
Kleinwachter, 208 



Kocher, 190 
Koeberle, 204, 205 
Kossmann, 186, 208 
Kraurosis vulvae, 23 
Kronig, 194 



Labia majora, 22 

minora, 22, 175, 176, 210 

glands, 211 

cysts, 211, 212 
Landau, L., 2, 4, 170 
Langhans, layer of, 107 
Leiomyosarcoma of the cervix, 68 
Leopold, 202 

Leucocytes in carcinoma alveoli, 62 
Lieberkiihn, 187, 188 
Ligamentum latum, 59, 139 (see Broad 
ligament) 

suspensorium ovarii, 139 

proprium, 139, 140 
Ligamentum teres, 178, 191, 192, 198 

fibroadenoma of, 191 

sarcoma of, 191 

sarcoadenoma of, 191 

cystofibroma, 191 
Lipoma (of the vulva), 26 
Liquor folliculi, 142 
Liquor ferri sesquichlorati, 15 
Lithium carbonicum, 13 
Liver, 6 

Lugol's solution, 17 
Lupus vulvae, 23 
Lutein cells, 144, 147, 150, 152 
Lymph cysts, 186, 192 
Lymph spaces, 157 
Lymph vessels, congestion of, in the 

tube, 123, 124 
Lymph vessels of the endometrium, 74 

perivascular, 102 
Lymphectasia, 207 
Lymphoma, 132 

M 

Maier, R., 106 

Malpighian body, 169, 181, 184, 197 

Mamma in dermoid cysts, 159 

Marchand, 106, 215 

Martin, 124, 129 

Martini, 221 

Maslowsky, 55 

Material, 1 

obtaining the, 2 
Medullary canal, 172 



232 



DvDEX. 



:N[edullary plates, 164, 167 
Medullary strands, 187 
Melanosarcoma of the vulva. 2S 
Membrana granulosa, 142, 143. 1S9 

propria of the glands, 99 

propria of the uterine glands. 73 
Menstrual anomalies, 75 
Menstruation. 145 

endometrium during, 74 
Mesenchym, 213 
Mesenterium commune, 165 
Mesentery. 167, 181 
Mesentery of Wolffian body, 177 
Mesoderm (parietal, visceral), 165, 

171, 172, 173, 213 
Mesonephros, 167, 168, 193 

adenoma. 181 

cystomata of the ovary. 188 
Mesosalpinx, 140. 148 
Mesovarium, 139 
Metaplasia, 67 
Methyl blue, 16, 17 

with sulphuric acid, 17 
Metritis, 108 

dissecans, 109 
Meyer. R.. 183, 189, 206 
Micro-organisms (staining of), 16 
Microscopical illusions, 33, 35 
Microtome (freezing), 6, 8. 10. 20 
Minot, 179 
Mixed tumors, of the kidney. 214 

rhabdomyoma. 214 

angiosarcoma. 214 

myxosarcoma, 214 

chondrosarcoma, 214 

of the cervix, 220, 221 

of the ovary, 216. 218 

of the testicle, 217 

of the vagina, 220, 221 
Morgagni. 116 
Mucoid polyp, 56 
Mucoid tissue, 67 
Mucous polyp of the tube. 171 
Miiller's fluid, 8, 18 

composition of, 18 
Miiller, duct of, 164, 174, 176. 177, 178, 

184, 185, 191, 200 
Muscle, smooth, 7 

striped, 7 
Muscle fibres, striated in cervix 
myoma, 68 

in mixed tumors (see Mixed 
tumors). 
Muscle of uterus, 70 



Muus, 215 

Myoma, uteri adeno-carcinomatosum, 
110 

interstitiale, intraparietale. intra- 
murale, 109 

ovaries in, 159 

submucosum, 109 

subserosum, 109 

enlargement of the tubes in. 137 
Myoma, of the cervix, 68 

cystic formations. 68 

sarcomatous degeneration. 104 

of the uterus. 110, 141 

degeneration. 109, 110 

calcification, 109 

of the vulva, 26 
Myom.etrium, 108 
Myosarcoma of the cervix, 68 

of the uterus, 101 
Myotom, 171, 213 
Myxadenoma polyposum of the cervix, 

54 
Myxofibroma of the ovary, 218 
Myxoid tissue, 177 
Myxoma (of the vulva), 26 
Myxosarcoma of the vulva, 26 

N 

Xabothi. 208 

Xagel. 173. 181, 182, 185, 186, 207, 208 

Natrium sulphuricum, 18 

Needle holder, 20 

Neoplasms, malignant. 25, 27, 57, 66, 
100, 102. 104. 138, 157 

Nephros, 164 

Nephrotom. 168. 171 

Nerve end bulbs, 23 

Nerves in dermoid cysts, 159 

Neurenteric canal, 164 

Nomenclature, gynecological-anatomi- 
cal, 92 

Nuck, 181, 191 

Nuclear inclusions in carcinoma, 61 

Nuclear division in carcinoma, 61 

Nymphae, 22, 211 

O 

Olshausen, 94 

Oophoritis interstitialis, 147 

Opitz, 201 

Orcein (Tanzer), 15 

Orth, 13, 47, 48, 102, 103 

Orthmann, 23, 127 

Osmic acid, 8 

Ova, primitive, 180 



IKDEX 



233 



Ovarian abscess. 136, 147 

adenoma, 187 

arteries, 140 

carcinoma, metastases, 156 

cysts, 138, 153, 188 

dermoids, 159. 216, z20 

gestation, 145 

ligament, 178 

mixed tumors. 216, 21/, 218 
Ovary, 164, 180, 181, 182, 188 

anatomical structure, 140 

disturbances of circulation, 146 

inflammations, 146 

infectious granuloma, 148 

microcystic degeneration, 148 

parasites. 148 

pregnancy. 145 

situation and external form, 139 
Ovary, 139 

carcinoma, 157 

cystoma or cystadenoma, 153 

disturbances of circulation, 146 

echi no coccus, 148 

fibrom, 158 

follicle. 142 

follicle cysts, 148 

gyratum, 145 

infectious granuloma. 148 

inflammation, 146 

myoma. 159 

neoplasms, 149 

parenchymatous layer. 141 

perithelioma, 159 

sarcoma. 159 

senile atrophy, 145 

surface papilloma. 150, 189 

syphilis, 148 

tuberculosis. 148 

vascular layer. 140 
Oviducts. 110 
Ovulation. 145 
Ovula Nabothi, 208 



Pachydermia of the portio, 50 
in cervix polyps. 54 

Pachysalpingitis. 134 

Papilloma ovarii, 156, 189 

Paradidymis. 190 

Paraflin embedding, 11 
oven. 20 
sections. 12. 13 

Parametritis. 2 

Parametrium, 59 



Paroophoral cysts of broad ligament, 
192 
myoma, 194 
Paroophoron, 182, 183, 184. 191, 192 
Parovarian rests, 185 
Parovarian cysts, 160, 1S6, 1S7 
Parovarium, 160, 164, 182, 185 
Perforation of the uterus. 103 
Perimetritis. 127 
Perineal folds, 175 
Perineal raphe, 175 
Perineum, 173, 175, 176 
Perioophoritis, 147 
Perisalpingitic process, 116 

bands, 125 
Perithelioma of the ovary, 159 
Peritoneum, 126, 141, 156 

parietal, pseudo-myxomatous de- 
generation, 156 
Peritonitis carcinomatosa, 158 
Perityphlitis, 128 
Peter, 23 

Pfannenstiel, 67, 107. 194 
Pfliiger, 181 

tubules of. 181 
Pick. 7, 60, 67, 187, 193, 194. 202 
Picric acid, 13 

Picrolithiocarmin (Orth). 13 
Pigment. 183, 191, 192, 194, 197 
Placenta. 82 

in extrauterine gestation. 107 
Placental polyps, 97 

of the tube, 122 
Placental villous tumors, malignant, 

107 
Pleural space. 165 
Plica phrenico-mesonephrica. 178 
Plica inguino-mesonephrica. 178 
Plicae palmatae. 32 
Pneumococci, 125, 128 
Poirier. 112 
Polyps of the external os. 49 

of the cervix. 52 

of the endometrium, 97 

of the tube. 122 
Pommer, 216 

Portio carcinoma, in speculum, 60 
Portio vaginalis, 28 

amputation. 50 

excision. 3 

in the newly-born. 48 

inflammation. 39 

ulcers, 40. 45, 46 
Post-anal prominence. 172 



234 



INDEX. 



Post-anal intestine, 172, 173 

Prickle cells, 30 

Primary follicle, 180 

Primary segment, 171 

Primary vertebrae, 164, 168 

Primitive furrow, 164 

Primitive trace, 164 

Primitive pericardial space, 165 

Processus vermiformis, 137, 139 

Prolapse, 49, 50 

Prominence of Mtiller, 174, 177 

genital, 175 
Prominence, anal, 175, 176 

epithelial, 175 
Pronephros, 167, 168 
Protoplasmic masses in chorioma, 116 
Protozoa, 61 
Pruritus vulvae, 23 
Pseudoglomeruli, 187, 191, 197 
Pseudomucin, 142, 149, 154 
Puncture, 1 
Pyosalpinx, 124 

R 

Razor, 6, 20 

Reactions (micro-chemical), 7 

Rectum, 173, 175 

Recurrence in cervix polyps, 55 

V. Recklinghausen, 109, 161, 162, 163, 
186, 191, 194, 195, 199, 200, 202, 
205 

Regeneration of uterine mucosa after 
menstruation, 75 
after labor, 79 

Resorcin (fuchsin), 15 

Resorption of the fetus in tubal gesta- 
tion, 122 

Rete testis, 184 

Rete Malpighii, 30 

Rhabdomyosarcoma of the cervix, 68 

Rhabdomyoma, 217 (see Mixed tu- 
mors) 

Ricker, 190 

Rieder, 190 

Rouget, 141 

Round-celled sarcoma of the endomet- 
rium, 104 

Ruge, 50, 57, 103, 106, 208 

Rugae vaginae, 26 



S 



Sactosalpinx, 124 
Safranin, 11 



Salpingitis catarrhalis, 125 

chronica productiva vegetans, 134 

follicularis, 134 

interstitialis disseminata, 134 

isthmica nodosa, 134, 201 

parenchymatosa chronica, 134 

pseudofollicularis, 134 

purulenta, 125, 127 
Salt solution, normal, 5 
Sanger, 106 

Sarcoadenoma of lig. teres, 191 
Sarcoma of the cervix, 66 

botryoides cerv. ut., 67 

chorion, 108 

chorion-deciduale, 108 

of the chorionic villi, 108 

deciduo-cellulare, 108 

diagnosis, 104 

of the endometrium, 104 

grape-like, 104 

in dermoid cysts, 220 

origin, 67 

of lig. teres, 191 

of the ovary, 159, 217, 218 

of the mucosa, 104 

of the uterine wall, 104 

of the vagina, 28, 221 

of the vulva, 26 

of the broad ligament, 192 

of the kidney, 214 

of the vagina in children, 221 

of the vagina in adults, 221 

of the cervix, 221 
Schatz, 56 
Schroder, 55, 57 
Schultze, B. S., 148 
Scissors, 3, 20 
Sclerotom, 171 
Sebaceous glands, 22 
Sections, 12 

fresh, 6 

staining, 13 

tangential, 34 

unstained, 6 
Seminal tubules, 184, 187 
Septic infection, 97 
Series sections, 8, 11 
Serotinal tumor, 108 
Serous covering of the tube, 112 
Sexual folds, 175, 176 
Sexual prominence, 175 
Sexual bands, 181, 184 
Sexual gland, 164, 170, 178 
Sims-Simon, 2 



INDEX. 



235 



Sinus urogenital! s, 164, 173, 174, 179 

Sinus urog. entodermal, 179 

Sinus urog. ectodermal, 179 

Sobotta, 144 

Softening (central) in cancer cones, 

102 
Spaces in cancer cones, 162 
Specimens, 9 

embedding of, 10, 11 

fixation, 8 

hardening and embedding, 8 

after test curettage, 1 

from the uterus, 4, 88 
Specula, 2 

after Landau and Abel, 2 

after Edebohls, 3 
Spee, 171, 180, 214 
Spermatocele, 190 

Spindle-celled sarcoma of the cervix, 
67 

of the endometrium, 104 
Spongy layer, 79 
Squamous epithelium, 14 

growth, 69 
Staining (in toto), 11 
Staining, 13 

elastic fibres, 15 

gonococci, 16 

micro-organisms, 16 

tubercle bacilli, 17 
Stratum germinativum, 30 
Streptococci, 125, 128 
Sublimate, 8 
Substance, contractile. 7 
Sulcus primitivus, 164 
Surface epithelium, 8 
Sweat glands, 22 
Switalski, 187 
Syncytial masses, 106 
Syncytioma malignum, 107 
Syncytium, 88, 106, 107 

T 

Tail, 165, 172, 173 

Tanzer, , 15 

Teratoma, 218 

Teratoma ovarii, 159, 162 

Test curettage from endometrium, 4 

Test excision from cervix, 3 

from vagina, 4 

from ext. genitalia, 4 
Testicle, 184, 187, 190, 207 
Theca folliculi, 142 

interna, 144, 148 



Tori medullares, 164 

Total extirpation of the uterus for 

portio carcinoma, 58, 59 
Transudate, 107 
Trichiasis vesicae, 221 
Trigonum vesicse, 178, 179 
Trimethylamin (in vag. cysts), 27 
Tuba P'^allopise, 110 
Tubal abortion, 122 
Tubal abscess, 127, 132, 136 
Tubal closure, congenital, 122 

acquired, 122 
Tubal folds, swelling of, 125 

hypertrophy, 131 

union, 133 
Tubal gestation, 107, 115, 116, 139 

results, 122 
Tubal muscularis, peristalsis, 117 
Tubal ostia, accessory, 115 
Tubal rupture in tubal gestation, 122 
Tubal sacs, 124, 131 
Tubal tumors, 124 
Tubal wall tumors, 117 

composition, 112 
Tube, sections of, 110 
Tube, accessory, 115, 174, 186 

actinomycosis, 137 

angles, 195 

adenomata, 195 

adenomyomata, 195 

corners, 193. 195 

carcinoma, 138 

closure of abdom. end, 125 

chorioma, 139 

cilia. 111 

disturbances of circulation, 122 

diverticula, 116 

fibroma, 139 

fimbrian end, 110 

hypertrophy, 137 

hyperplasia, 137 

infantile, 115 

infectious granuloma. 137 

interstitial portion, 110 

isthmus. 111 

infiammations, 124 

lymph vessels, 112, 113 

malformations, 115 

menstruation, 114 

mucosa, 113 

mucous polyps, 138 

muscle, 112 

myoma, 139 

neoplasms, 138 



236 



INDEX 



Tube, normal, 110 

papillary carcinoma, 139 

papilloma, 138 

pregnancy changes, 116 

senile changes, 115 

situation and course, 111 

syphilis, 137 

supernumerary, 115 

tuberculosis, 137 

union with other organs, 126 
Tubercle, 69, 108 
Tubercle bacilli, 17, 23, 27, 68, 108, 

137, 148 
Tuberculosis of the endometrium, 108 
Tubo-ovarian tumor, 124, 134, 148 
Tubo-parovarian canal, 185 
Tubules, 167 

head kidney, 167, 168 ' 

Tubules of Pfliiger, 181 
Tubuli seminiferi, 184 

recti, 184, 187 
Tunica fibrosa folliculi, 142 

propria folliculi, 142 
Twisting of pedicle (ovarian tumors), 
i56 

U 

Ulcera carcinomatosa in elongatio 

colli, 52 
Unna, 16, 24 
Urachus, 179 
Ureter, 140, 173, 174, 177, 180 

accessory, 207 
Urethra, 173, 174, 178 
Urethritis gonorrhoica, 51 
Urogenital fold, 177, 178 
Urogenital plate, 175 
Urogenital opening, 164 
Urogenital sinus, 164, 173, 174, 175, 

177 
Urorectal septum, 173 
Uterus, dilatation, 4 

adenomyomata, 195, 199, 200 

cysts and glands, 193, 194 

dermoid cysts, 222 

duct of Gartner in, 204 

fibroma, 109 

grasping the, 2 

hypertrophy, 109 

infiammation, 108 

myoma, 109 

normal, 69, 70 

neoplasms, 100 

origin of (see Duct of Miiller) 



Uterus, sarcoma, 104 

sounding, 4 

subperitoneal cystoma, 194 

test excision, 4 
Uterine carcinoma, 100 
Uterine glands, 71, 72 

destruction in sarcoma, 104 

invagination, 73 

membrana propria, 73 

V 

Vacuoles, 106 

Vagina, 26, 164, 176, 178 

carcinoma, 27 

cysts, 28, 206, 207, 208 

connective-tissue neoplasms, 28 

duct of Gartner in, 206 

hypertrophy, 27 

inflammation, 27 

mixed tumors, 221, 222 

neoplasms, 27 

normal, 26 

rudimentary, 207 

sarcoma, 28, 221 

ulcerations, 27 
Vas deferens, 184 
Vasa efferentia, 190 

aberrantia, 190 
Veit, 48, 57 
Veith, 207 

Vertebrae, 164, 176, 179 
Vestibulas epithelium, 210 
Vestibulum, 26, 164, 176, 179 
Villi, adherent, 88 

in tubal gestation, 119 
Vulva, atrophy, 23 

conn, tissue hypertrophy, 25 

conn, tissue neoplasms, 26 

carcinoma, 25 

cysts, 26, 211 

glands, 210, 211 

inflammation, 23 

neoplasms, 25 

normal, 22 

pointed condyloma, 24 

ulceration, 23 
Vulvitis gonorrhoica, 24 

W 

Waldeyer, 105, 106, 107, 110, 139, 140, 

155, 183, 207 
Wall — sarcoma of wall of uterus, 104 
Water, 6 
Webster, Clarence, 119, 120, 122 



INDEX. 



237 



Weigert, 15 

Wertheim, 17 

Williams, 56 

Wilms, 215 

Winckel, 55 

Wolffian duct, 28, 109, 167, 168, 169, 

171-180, 182, 184, 185, 189 
Wolffian body, 109, 160, 161, 162, 165, 

168, 170, 171, 173-180, 183, 185, 

187, 189, 190, 192, 194, 197, 212, 

213 

X 
Xylol, 13, 16 

Canada balsam, 13 



Yellow body of Waldeyer, 190 



Z 



Zenker's fluid, 8 
Ziegler, 103 
Zona pellucida, 142 
Zona parenchymatosa, 181 
Zona vasculosa, 181 
Zweifel, 215 



